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Full text of "Cyclopaedia of the diseases of children, medical and surgical"

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COLLEGE OF PHYSICIANS 
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CYCLOPEDIA 



OF THE 



Diseases of Children 



MEDICAL AND SURaiCAL. 



THE ARTICLES WRITTEN ESPECIALLY FOR THE WORK BY 
AMERICAN, BRITISH, AND CANADIAN AUTHORS. 



EDITED BY 

JOHN M. KEATIKG, M.D. 



VOL. IV. 



ILL USTBATED. 



PHILADELPHIA: 

J. B. LIPPINCOTT COMPANY. 

18 90. 



Copyriglit, 1S90, by J. B. Lippixcott Company. 




•mg 



CONTENTS OF VOLUME IV. 



PART I. 
THE EAR. 



PAGE 

DISEASES OF THE EAR IN CHILDREN. By Charles H. Btjenett, 

M.D., Philadelphia, Pa., Professor of Otology, Philadelphia Polyclinic, etc. . . 1 



PART II. 
THE EYE. 



AFFECTIONS OF THE EYELIDS, LACHRYMAL APPARATUS, CON- 
JUNCTIVA, AND CORNEA. By Geo. E. de Schweinitz, M.D., Phila- 
delphia, Pa., Ophthalmic Surgeon to the Philadelphia Hospital and to the Chil- 
dren's Hospital ; Ophthalmologist to the Orthopedic Hospital and Infirmary for 
Nervous Diseases ; Dispensary Surgeon to the Hospital of the University of 
Pennsj'lvania, etc 50 

DISEASES OF THE EYE. By Charles S. Turnbull, M.D., Philadelphia, 
Pa., Ophthalmic Surgeon to the German Hospital, to the Mary J. Drexel Home, 
etc., and George M. Gould, M.D., Philadelphia, Pa., Ophthalmic Surgeon to 
the Philadelphia Hospital ; Chief of Clinic, Ophthalmic Department of the Ger- 
man Hospital 120 

OPHTHALMOSCOPY: LOCAL DISEASES AND FUNCTIONAL DIS- 
ORDERS OF THE CHOROID, OPTIC NERVE, AND RETINA, 
By Charles A. Oliver, 31. D., Philadelphia, Pa., Ophthalmic Surgeon to St. 
Agnes' Hospital ; Consulting Ophthalmic Surgeon to St. Mary's and Maternity 
Hospitals 158 



PART III. 
HYGIENE. 



PHYSICAL DEVELOPMENT. By John M. Keatikg, M.D., Philadelphia, 
Pa., Visiting Obstetrician to the Philadelphia Hospital; Gynaecologist to St. 
Joseph's Hospital ; Consulting Physician for the Diseases of Women, St. Agnes' 
Hospital, and James K. Young, M.D., Philadelphia, Pa., Instructor in Ortho- 
psedic Surgery ; Attending Orthopaedic Surgeon, University Hospital ; Fellow of 

the College of Physicians, etc 241 

iii 



IV CONTENTS OF VOLUME IV. 

PAGE 

MASSAGE. By Wm. A. Edwards, M.D., San Diego, California, formerly In- 
structor in Clinical Medicine and Physician to Medical Dispensary, University 
of Pennsylvania ; Pellow of the College of Physicians of Philadelphia, etc. . . 325 

PROPHYLAXIS OF DISEASE IN CHILDREN. By J. Wellington 

Byers, M.D., Charlotte, N.C 332 

SCHOOL-HYGIENE. By D. F. Lincoln, M.D., Boston, Mass., formerly In- 
spector of Schools under the State Boards of Health of New York, Connecticut, 
and Massachusetts, etc 343 

CONSTRUCTION OF CHILDREN'S HOSPITALS, Etc. By Lindley 

Johnson, Philadelphia, Pa., Architect, Ecole des Beaux- Arts, Paris 409 

JUVENILE CRIME, AND PUBLIC METHODS OF PREVENTION AND 
RECLAMATION. By J. Percy Keating, Esq. (Georgetown), of the Phila- 
delphia Bar ■ 422 

MEDICO-LEGAL TESTIMONY. By Jerome Walker, M.D., Brooklyn, 
IST.Y., Lecturer on Physiology and Hygiene, Brooklyn High School; formerly 
Lecturer on Hygiene, Long Island College Hospital ; Physician to the Brooklyn 
Seaside Home for Children and to the Brooklyn Society for the Prevention of 
Cruelty to Children , 435 



PART IV. 
DISEASES OF THE NERVOUS SYSTEM. 

GENERAL INTRODUCTION TO THE DIAGNOSIS OF DISEASES 
OF THE NERVOUS SYSTEM. By Allan McLane Hamilton, M.D., 
New York, one of the Consulting Physicians to the Hospital for Nervous Dis- 
eases ; Consulting Physician to the New York City Asylum for the Insane, 
Hudson Kiver State Hospital for the Insane, Hospital for Kuptured and Crippled, 
New York, etc 447 

HYDROCEPHALUS: DROPSY OF THE BRAIN, WATER ON THE 
BRAIN. By Francis T. Miles, M.D., Baltimore, Md., Professor of Physiol- 
ogy and Clinical Professor of Diseases of the Nervous System, University of 
Maryland ; former President of the American Neurological Society 466 

CEREBRAL PALSIES AND SUPPURATIVE MENINGITIS. By Lan- 

DON Carter Gray, M.D., New York, Professor of Nervous and Mental Diseases 
in the New York Polyclinic ; former President of the American Neurological 
Society; formerly President of the New York Neurological Society; President 
of the Neurological Section of the New York Academy of Medicine ; President 
of the Society of Medical Jurisprudence, etc 479 

MULTIPLE CEREBRO-SPINAL SCLEROSIS. By William Broaddus 
Pritchard, M.D., New York, Lecturer on Mental and Nervous Diseases, New 
York Polyclinic 495 

TUBERCULAR MENINGITIS. By A. Jacobi, M.D., New York, ex-President 
of New York Academy of Medicine ; Clinical Professor of Diseases of Children 
in the College of Physicians and Surgeons, New York, etc 514 

CEREBRAL HEMORRHAGE, THROMBOSIS, AND EMBOLISM. By B. 
Sachs, M.D., New York, Professor of Mental and Nervous Diseases in the New 
York Polyclinic ; Neurologist to the Montefiore Home for Chronic Invalids, etc. 525 



CONTEXTS OF VOLUME IV. V 

PAGE 

INTRACRANIAL TUMORS. By M. Allen Starr, M.D., New York, Pro- 
fessor of Diseases of the Mind and Nervous System, College of Physicians and 
Surgeons, New York, etc 551 

AFFECTIONS OF THE NERVOUS SYSTEM IN HEREDITARY SYPH- 
ILIS. By Abner Post, M.D., Boston, Mass., Instructor in Syphilis at Har- 
vard University, etc 590 

TOXIC AFFECTIONS FROM ARSENIC AND LEAD. By J. J. Putnam, 
M.D., Boston, Mass., Instructor in Diseases of the Nervous System, Harvard 
Medical College ; Out-Patient Physician for Diseases of the Nervous System at 
the Massachusetts General Hospital 599 

MYELITIS, SPINAL MENINGITIS, AND HEMORRHAGE INTO THE 
SPINAL CORD OR MEMBRANES. By Mary Putnam Jacobi, M.D., 

New York, Professor of Therapeutics at the Women's Medical College, etc. . . 643 

POLIOMYELITIS ANTERIOR. By Wharton Sinkler, M.D., Philadelphia, 
Pa., Attending Physician to the Philadelphia Orthopaedic Hospital and Infirmary 
for Nervous Diseases ; Neurologist to the Philadelphia Hospital, etc 683 

HEREDITARY ATAXIA AND LOCOMOTOR ATAXIA. By Charles L. 
Dana, M.D., New York, Professor of Nervous and Mental Diseases, New 
York Post-Graduate School ; President of the New York Neurological Society ; 
Visiting Neurologist to the New York Infants' Asylum, etc 716 

STRUCTURAL ABNORMALITIES OF THE BRAIN AND CORD. By 
Sarah J. McNutt, M.D., New York, Member of the Academy of Medicine; 
Member of the Pathological Society, etc., and Sarah E. Post, M.D., New 
York : 728 

THE SURGICAL TREATMENT OF ABNORMALITIES OF THE 
BRAIN AND SPINAL CORD. By P. S. Conner, M.D., Cincinnati, 
Ohio, Professor of Surgery in the Medical College of Ohio and in the Dart- 
mouth Medical College, etc 741 

THE OPERATIVE SURGERY OF THE BRAIN AND SPINAL CORD. 
By Charles B. Nancrede, M.D., Ann Arbor, Michigan, Professor of Sur- 
gery and Clinical Surgery in the University of Michigan ; late Senior Surgeon 
to the Protestant Episcopal Hospital ; late Surgeon to Jefferson Medical College 
Hospital; Corresponding Member of the Eoyal Academy of Medicine of Eome, 
etc. 748 

DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. By John 
Van Bibber, M.D., Baltimore, Md., Attending Physician to the Dispensary for 
Nervous Diseases 788 

PRIMARY MUSCULAR ATROPHIES. By James Stewart, M.D., Mon- 
treal, Canada, Professor of Pharmacology and Therapeutics, McGill University; 
Director of the Univei-sity Clinic for Diseases of the Nervous System ; Assistant 
Physician to the Montreal General Hospital, etc 812 

HEADACHE. By E. C. Seguin, M.D., New York, Member of the New York 

Neurological Society, etc ^28 

CHOREA, By B. Sachs, M.D., New York, Professor of Mental and Nervous 
Diseases in the New York Polyclinic ; Neurologist to the Montefiore Home for 
Chronic Invalids, etc ^40 

CONVULSIONS IN INFANCY AND CHILDHOOD. By Morris J. Lewis, 
M.D., Philadelphia, Pa., Visiting Physician to the Children's Hospital; Visit- 
ing Physician to the Orthopajdic Hospital and Infirmary for Nervous Diseases ; 
Visiting Physician to the Pennsylvania Hospital, etc 857 



Vi CONTENTS OF VOLUME IV. 

PAGE 

EPILEPSY. By Landon Carter Gray, il.D., New York, Professor of Nervoxas 
and Mental Diseases in tlie ISTew York Polyclinic ; former President of tlie Amer- 
ican Neurological Society ; formerly President of the New York Neurological 
Society ; President of the Neurological Section of the New York Academy of 
Medicine ; President of the Society of Medical Jurisprudence, etc 899 

TETANUS. By P. X. Dercum, M.D., Philadelphia, Pa., Instructor in Nervous 
Diseases, University of Pennsylvania ; Neurologist to the Philadelphia Hospital, 
etc 913 

ATHETOSIS.— CATALEPSY.— THOMSEN'S DISEASE. By George W. 
Jacoby, M.D., New York, Physician to the Department of Nervous Diseases, 
German Dispensary, etc 937 

EXOPHTHALMIC GOITRE. By JoH^r K. Mitchell, M.D., Philadelphia, 
Pa., Physician to St. Agnes' Hospital; Assistant Physician to the University 
Hospital and to the Infirmary for Nervous Diseases ; Assistant Demonstrator of 
Clinical Medicine in the University of Pennsylvania, etc. S52 

HYSTERIA. By Charles K. Mills, M.D., Philadelphia, Pa., Lecturer on 
Mental Diseases, Univereity of Pennsylvania ; Neurologist to the Philadelphia 
Hospital ; Professor of Diseases of the Mind and Nervous System, Philadelphia 
Polyclinic and College for Graduates in Medicine, etc 958 

THE DISORDERS OF SLEEP. By Charles P. Putxam, M.D., Boston, 

Mass., Physician to the Massachusetts Infants' Asylum, etc 1008 

IDIOCY AND IMBECILITY. By Edward N. Brush, M.D., Philadelphia, 

Pa., Assistant Physician to the Pennsylvania Hospital for the Insane, etc. . . 1019 

INSANITY. By E. C. Spitzka, M.D., New York 1038 



LIST OF ILLUSTRATIONS TO VOLUME IV. 



PLATES. 

PAGE 

Micro-Photograph from a Section of Dermoid Tumor of the Cornea, showing 

the General Structure (Fig. 14) facing 118 

Micro-Photograph from same Section, more highly magnified (Fig. 15) ... " 118 
Normal Eye-Ground of an Individual with Light-Brown Hair (Clirorao- 

lithograph) " 158 

Retained Nerve-Sheaths " 162 

Coloboma of the Choroid " 163 

Undue Tortuosity of the Eetinal Vessels '■ 165 

Anomalous Venous Distribution on the Disk (Photo. IV.) " 174 

Post-Ocular Sarcoma of the Optic Nerve (Photo. V., Figs. 1 and 2) " 174 

Embolism of the Central Artery of the Eetina (Photo. VI.) " 178 

Optic Neuritis of General Anaemia (Photo. VII.) " 178 

Progressive Development of Hemorrhages in Pernicious Ansmia " 182 

Retinal (Edema and Vascular Opacity in Leucocyth^mia (Photo. 

VIII.) between 182 and 183 

Same Eye-Ground Nine Weeks later (Photo. IX.) " 182 and 183 

Neuro-Pvetinitis of Intracranial Tumor (Photo. X.) facing 188 

Partial Post-Neuritic Atrophy (Photo. XI.) " 188 

Regressive Neuro-Eetinitis of Intracranial Tumor (Photo. XII.) " 188 

Acute Nephritic Eetinitis (Photo. XIII.) " 211 

Chronic Eetinal Changes in Albuminuria (Photo. XIV.) " 211 

Partial Absorption of Hemorrhagic Opacities in the Vitreous " 213 

Tuberculosis of the Eetina and Choroid " 228 

Eetinitis Pigmentosa " 235 

Glaucomatous Excavation " 237 

Walking Child (Photo. I.) " 266 

Eunning High Jump (Photo. V.) " 266 

Punning Child (Photo. II ) between 268 and 269 

Eunning Boys (Photo III.) " 268 and 269 

Eowing Man (Photo. IV.) facing 270 

Swedish Gymnastic Movements. — Neck Eest Standing, Heels Eising Position 
(Photo. VI.) ; Neck Eest Standing, Trunk Change Turning Position 
(Photo. VII.) ; Stretch Standing, Trunk Sideways Bending Position 
(Photo. VIII.) ; Stretch Stride Standing, Trunk Forward Bending Posi- 
tion (Photo. IX.) ^ " 321 

Swedish Gymnastic Movements.— Half Stretch Walk, Standing Position 
(Photo. X.); Stretch Walk Standing, Trunk Turning Position (Photo. 
XI.) ; Yard Walk, Fall Standing Position (Photo. XII.) ; Stretch Stand- 
ing, Heels Eising, Knee Bending Position (Photo. XIII.) " 323 

Plan of First Floor of a Twenty-Bed Hospital between 418 and 419 

Sketch of a Small Country Hospital " 418 and 419 

Plan of a Country Hospital facing 420 

Three- Ward Hospital (Fig. 15) (folded between Plates III. and V.). between 420 and 421 

vii 



VUl LIST OF ILLUSTRATIONS TO VOLUME IV. 

PAGE 

Sketch of a Small Country Hospital facing 421 

Case of Spastic Diplegia (Photo. I.) . . . , hetween 546 and 547 

Case of Congenital Diplegia (Photo. II.) '• 546 and 547 

Case of Poliomyelitis Anterior, showing Atrophy of Eight Leg facing 699 

Case of Priedreich's Ataxia " 722 

Priedreich's Ataxia. — Priedreich, Yirchow's Archiv, Bd. Ixx. 

(Pig. 5) ; Kutimeyer and Quincke, Virchow's Archiv, Bd. 

xci. (Pig. 6) ; Eutimeyer, Virchow's Archiv, Bd. xci. (Fig. 7) . hetween 724 and 725 
Friedreich's Ataxia. — Gowers and Pitt, Guy's Hospital Eeports 

(Pig. 8) ; Erlitki and Eibalkin, Archiv f. Psych., 1886 (Pig. 9) " 724 and 725 



FIGURES. 

PAGE 

Infant's Temporal Bone (Gray) 2 

Left Tympanic Cavity laid open (Burnett) 3 

Hand-Mirror 7 

Forehead-Mirror , 7 

Outer Surface of Drum-Memhrane, magnified 3 J- Times (Politzer) 14 

Politzer's Inflation-Bag 20 

Application of the Inflation-Bag 20 

Cotton-Holder 21 

Burnett's Method of insufllating Powder into the Ear 22 

Paracentesis-Knife 22 

Nervous Connection between the Teeth and the Ear (Woakes) 23 

Burnett's Polyp-Snare 25 

Bivalve Speculum for examining the Anterior Nares 34 

Ectropion the Eesult of a Wound from the Tine of a Pork 63 

Ectropion of Upper Lid after Injury to the Brow 63 

Symhlepharon of Upper Lid following Purulent Ophthalmia 64 

Epicanthus (after Von Amnion) 67 

Colohoma Palpebrarum (after Manz) 68 

Phlegmonous Dacryocystitis 73 

Ophthalmia Neonatorum 80 

Symhlepharon of Upper Lid following Purulent Ophthalmia 81 

Phlyctenular Ophthalmia 94 

Diphtheritic Ophthalmia 97 

Essential Shrinking of the Conjunctiva 100 

Staphyloma of the Cornea 107 

Dermoid Tumor of the Cornea 119 

Antero-Posterior Vertical Section through the Globe and Orbit (Pig. 1). Frontal 
Section of the E^-e and Orbit (Pig. 2). Schematic Section of the Globe of the 

Eye (Pig. 3.) . 122 

Persistence of the Pupillaiy Membrane 124 

Symmetrical Ectopia Lentis 126 

Diagrammatic Illustration of Emmetropia 140 

Diagrammatic Illustration of Hyperopia . . .' 141 

Diagrammatic Illustration of Myopia 142 

Diagrammatic Illustration of Astigmatism 144 

"Wharton Jones's Operation for Ectropion 152 

Hasner d'Artha's Blepharoplastic Operation 153 

Operation for Corneal Staphyloma 154 

Iridectomy 154 

Discission, or Needling (Fig. 16) ; same with Two Needles (Fig. 17) 155 



LIST OF ILLUSTRATIONS TO VOLUME IV. IX 

PAGE 

Diagram representing Heights from Actual Measurement of Four Hundred and 

Thirty English Public-School Boys from Eleven to Twelve Years Old .... 2-48 

Eise and Fall and Onward 3Iovement of Head in Walking (Fig. 2 a). Lateral 
Sway of Head in "Walking (Fig. 2 b). Eise and Fall and Forward Movement 

of Eight Hip in Walking (Fig. 2 c). Lateral Sway of Hip in Walking (Fig. 2 d) 266 

Rise and Fall of Left Foot in Walking (Fig. 2 e). Lateral Sway of Left Foot in 

Walking (Fig. 2/) 207 

Eise and Fall and Onward Movement of Eight Foot of Eunning Boy 269 

Eise and Fall of Head in Eowing 270 

Eise and Fall of Hand in Eowing 270 

Eise and Fall and Onward Movement of Eight Foot in High Jumping 273 

Swedish Gymnastic Positions and Movements : 

Fout Grasp, Wing Forward, Falling Position 304 

Wing Balance Standing, Knee Bending and Extending 305 

Balance Walking on Horizontal Bar 305 

Wing Standing, Legs Lifting Sideways 306 

Stretch Stride Standing, Trunk Backward Bending with Support 306 

Arch Support Standing, Knee Flexing and Extending 307 

Hanging Position 308 

Underhanging, Double Arm Flexion 308 

Bent Hanging, Double Knee Extending 309 

Bent Underhanging, Hand Walking 309 

Inclined Eope Climbing Upward 310 

Yard Stride Standing, Trunk Forward Bending 310 

Yard Forward Lying, Arm Bending and Stretching Sideways 311 

Stretch Forward Lying, Arm Bending and Stretching Upward 311 

Stretch Lying, Legs Elevating 311 

Stretch Knee Stride Standing, Trunk Backward Bending 313 

Feet Fixed, Wing Sitting, Trunk Backward Bending 313 

Feet Fixed, Arms Stretch Sitting, Trunk Backward Falling 313 

Stoop Falling Position 314 

Horizontal Stoop Falling Position 314 

Eeverse Stoop Falling Position 314 

Arms Bent, Support Falling, Leg Elevating 316 

Foot Fixed, Stretch Balance Standing, Trunk Sidewaj's Bending 316 

Arms Bent, Trunk Turn, Stride Standing, Arm Extending 316 

Half Stretch, Half Support, Side Falling, Legs Elevating 317 

Sideways Hanging Position 317 

Jumping in Height on the Place 318 

Eunning Jump 319 

High Jumping 319 

Vaulting . 320 

Diagram showing how the Body is supported on the Legs (Fig. 1). Diagram show- 
ing the Pelvis or Hip-Boue and the Lower Part of the Spinal Column tilted 

to the Eight when the Eight Leg is shortened (Fig. 2) 355 

Curvature of Spine, caused by the Eaising of the Eight Shoulder by a High Desk 

or Table " 356 

A Comfortable School-Chair (Fig. 4). Liebreich's Desk and Seat (Fig. 5). Varren- 
trapp's Desk and Adjustable Seat (Fig. 6). Yarrentrapp's Seat and Desk 

compared with a Boston School-Chair and Desk (Fig. 7) 360 

American Curved-Back Seat and Desk, and Buchner's Pattern, for Corresponding 

Ages 362 

American Model of Yarrentrapp's Seat and Desk (Fig. 9). Belgian Model in the 

Philadelphia Exhibition of 1876 (Fig. 10) 363 

Diagram illustrating Proper Position of Manuscript on Desk in Writing 364 

Mott's System of School- Ventilation by Flues 382 



X LIST OF ILLUSTRATIONS TO VOLUME IV. 

PAGE 

Section of the Bridgeport High School 382 

Partial Section from Pront to Piear of the Bridgeport High School (Pig. 14). Cellar- 
Plan of same School (Fig. 15) 383 

Diagrams illustrating the Principle of Ventilation by Heated Flues (Figs. 16, 17) . 384 

Diagram illustrating the Method of Ventilation of Two Stories 385 

Wolpert's Apparatus for testing Purity of Air 392 

Eequirements for the Drainage-Pipes of a House 397 

Compound of Water-Closet and Latrine 399 

System of Deodorizing School Privies (Figs 22, 23) 401 

Temporary ATrangement for Deodorizing School Privy 402 

Movable Trough for Cleaning School Privy 402 

Block-Plans of Leading Pavilion Hospitals, showing Various Treatments of the 

Ward 411 

Faulty and Proper Isolation of Ward Annex (Figs. 7 and 8) 413 

Ordinary Floor 417 

Mill-Constructed Floor 417 

Hospital Walls 418 

Plan of a Cottage Hospital, Twelve Beds 420 

Method of Ascertaining Condition of Reflex in the Tendo Achillis 454 

Electrode 455 

Method of Diagnosing Paralysis by Electricity 458 

Examination of Reflexes with Percussion-Hammer 459 

Brissaud's Apparatus for Registering the Knee-Jerk 459 

McLane Hamilton's Dynamograph 462 

Seguin's Thermometer 465 

Steward's Surface Thermometer 465 

Meningeal Hemorrhage in a New-Born Child (after Dr. Sarah J. McNutt) .... 526 
Extent of Pachymeningitis Htemorrhagica over Superior Surfaces of Hemispheres in 

a Case of Cerebral Hemorrhage (Sachs and Peterson) 527 

Extent of Process on Inferior Surfaces of the Left Hemisphere in the same case 

(Sachs and Peterson) 528 _ 

Cyst formed by Softening of Brain-Substance secondary to Obstruction of Middle 

Cerebral Artery beyond the First Branch (after Ashby and Wright) 533 

Deformities in Cases of Infantile Cerebral Palsy (Figs. 5, 6, and 7) 536 

Movements of the Normal and of the Paretic Hand 539 

Case of Paraplegia. Photographed during an Epileptic Seizure 540 

Cortical Sensory-Motor Areas and Visual Areas 565 

Cortical Speech Areas 570 

Lateral View of the Brain 573 

Ataxiagram-Tracings in a Case of Friedreich's Disease. Patient Standing, with 
Eyes closed Thirty Seconds (Fig. 1). Same Patient, Sitting, with Eyes closed 

(Fig. 2) 721 

Ataxiagrams of a Case of Typical Locomotor Ataxia of Seven Years' Standing. 
Patient Standing, Eyes closed Thirty Seconds (Fig. 3). Same Patient, Sitting, 

Eyes closed (Fig. 4) 721 

Case of Meningocele (Fig. 1). Section of Skull (Fig. 2) 731 

Bilateral Symmetrical Porencephalus. — Left Hemisphere. Atrophy of the Ascend- 
ing Frontal Convolution, of the Ascending Parietal Convolution, of the Para- 
central Lobule, and possibly of the Anterior Part of the First Temporal Con- 
volution (about Two-Thirds Actual Size) 737 

Bilateral Symmetrical Porencephalus. — Right Hemisphere. Atrophy of the As- 
cending Frontal Convolution, of the Ascending Parietal Convolution, and of 

the Paracentral Lobule (about Two-Thirds Actual Size) 737 

Bilateral Symmetrical Porencephalus. — The Right Hemisphere viewed from above . 738 
Bilateral Symmetrical Porencephalus. — Vertical Section, showing the Atrophied 

Piiscentral Convolution 738 



LIST OF ILLUSTRATIONS TO VOLUME IV. XI 

PAGE 

Bilateral Symmetrical Porencephalus. — Internal Aspect of the Eight Hemisphere, 
showing the Atrophied Paracentral Lobule with the Atrophied Band in the 

Callosum 738 

Case of Hydrocephalus 746 

Instruments for the Operation of Trephining : 

Hopkins's Eongeur (Fig. 1) 752 

Elevator (Fig. 2) 752 

Trephine-Brush (Fig. 3) 752 

Hey's Saws (Fig. 4) 752 

Conical Trephine (Fig. 5) 753 

Old-Pattern Trephine (Fig. 6) 753 

Horsley's Periosteal Elevator (Fig. 7) 754 

Operation of Trephining (Fig. 8) 754 

Lenticular (Fig. 9) 756 

Proper and Improper jMethods of arranging Gut Threads for Capillary Drainage 

after Trephining (Figs. 10 and 11) 757 

Brain Electrode 760 

Aluminium Probe 765 

Self-Closing Eat-Toothed Forceps 767 

Diagram showing Points for Application of Trephine in Operating for Intracranial 

Hemorrhage, Cerebral Abscess, and Cerebellar Abscess 771 

Simple Form of Cyrtometer = 774 

Wire Serres-Fines 775 

Horsley's Trephine (Fig. 18) and Forceps (Figs. 19 and 20) 776 

Nunneley's Forceps 778 

Horsley's Flexible Knife 778 

Antero-Posterior Section of the Head One-Half Inch from the Middle Line .... 783 

Transverse Section of the Head One and a Quarter Inches behind the Meatus . . . 783 

Case of Left Facial Hemiatrophy 826 

Diagrammatic Illustration of Convulsions 861 

Tracings showing ISTumber of Deaths in Minors from Gastro-Intestinal Disorders, 
with the Mortality from Convulsions, per Month, in Philadelphia, from 1876 to 

1885 inclusive 872 

Myotonia Congenita. Quadriceps Femoris. Transverse Section. X 300 946 

Myotonia Congenita. Quadriceps Femoris. Transverse Section of a Muscle-Fibre. 

X 1200 947 

Segment of a Muscle-Fibre from Myotonia Congenita. Quadriceps Femoris. Lon- 
gitudinal Section. X 1200 948 

Case of Onanism 1049 

A Subject of Moral Irnbecility 1052 



CYCLOPEDIA 



OF THE 



DISEASES OE CHILDREK 



PART I. 
THE EAR. 



DISEASES OF THE EAR IN CHILDREN. 

By CHAELES H. BUENETT, M.D. 



DISEASES OF THE EXTEEI^AL EAR. 

In the following pages those under fifteen years of age are considered 
children. The percentage of children in ear-cases varies in different coun- 
tries, or in diiFerent parts of the same country. Marian, of Bohemia, states 
that twenty-five per cent, of his cases of ear-disease are children, about 
equally divided between the sexes. Biirkner, of Gottingen, places the per- 
centage at forty-seven and three-tenths, and Bezold, of Munich, places it 
at twenty-one and two-tenths, respectively, in their experience. 

In this country, Blake, of Boston, finds that twelve per cent, of his 
cases are children. Spencer, of St. Louis, states that in private practice 
seventeen per cent, of his cases are children, while in the public clinic 
children constitute twenty-seven per cent, of the cases. In New York A. 
H. Buck finds twenty per cent, of his cases in private practice are children, 
and Sexton gives fifteen per cent. My own experience shows that in Phila- 
delphia twenty-two and a half per cent, of the cases in the Polyclinic are 



DISEASES OF THE EAR IX CHILDEEX. 



children, while in private practice the percentage is eight and a half in my 
last two hundred consecutive cases. 

The auditory apparatus of a child differs in some respects from that 
of an adult. In the child the auricle and the auditory canal are much 
smaller than in the adult, while the membrana tympani and the ossicles in 
the middle ear are of full size at birth. The drum-cavity is of the same 
size in the new-born child as in the adult, but there is no mastoid process 
in connection with it, as the mastoid cells are developed at a later period. 
The internal ear is the same in the child as in the adult, though the semi- 
circular canals stand out in the cranial cavity, free from the dense osseous 
tissue which Ad ally encases them in the older bone. These differences, 
especially those in the external ear, should receive a little closer regard. 
Therefore the reader's attention is called to the following anatomical de- 
scription. 

The external ear of the child consists of the auricle and a fibro- 
cartilaginous auditory canal, the latter being terminated at its fundus by 

the membrana tympani. In the 
adult M'e find between the auricle 
and the membrana tympani an 
osseous canal, an inch or more in 
length. In the child, however, 
there is no osseous auditory canal 
in its complete state. Between 
infancy and maturity the annulus 
tympanicus may be said to be 
gradually transformed into aa 
osseous tube. Natural dehis- 
cences persist in the anterior wall 
of the auditory canal, sometimes 
until the fifth year. They are 
aualoo-ues of the incisurse Santo- 



FlG. ]. 



1 for squamous 
portion, in- 
cluding zygo- 
ma. Second 
month. 



Ifor auditory 
process. 



1 for petrous and 
mastoid por- 
tions. 



1 for styloid pro- 
cess. 




rini 



Infant's temporal bone. (Gray.) 



the annulus tympanicus. (Fig. 1.) 



At birth the temporal bone 
consists of three separate parts, 
— the pyramid, the squama, and 
By the end of the first year of life 
osseous union has taken place between these parts. The child's temporal 
bone, however, is very different from that of the adult. Development con- 
tinues until the age of puberty, when the bone is complete. In the pyramid 
of the young child, in that part containing the internal ear, the semicircular 
canals are not covered in by the cancellated tissue which is found later in 
life. In the squama we find no developed mastoid cells, — merely the trace 
of an antrum. The external osseous auditory canal does not exist, excepting 
in the annulus tympanicus, which finally develops outwardly into the bony 
canal. The auricle is joined to the annulus tympanicus by fibrous tissue, is 



DISEASES OF THE EAR IX CHILDREX. 



Fig. 2. 




very pliable, but quite short, which brings the coucha of the auricle very- 
much, nearer the drum than in older children or in adults. Hence the 
membrana tympani in the infant may be said to be superficially placed, and 
easily reached — sometimes very unfortunately so — by any one manipulating 
in the external meatus. 

The middle ear, or tympanic cavity, is the space lying between the 
outer surface of the pyramid and the inner surface of the annulus tym- 
panicus, and the membrana tympani, 
and bounded behind by the union of 
the squama and the pyramid in the 
region of the mastoid antrum. An- 
teriorly the tympanic cavity is open to 
the Eustachian tube. 

In the tympanic cavity are swung 
the three auditory ossicles, — the mal- 
leus, the incus, and the stapes. The 
first is inserted by its so-called handle 
into the membrana tympani, and by its 
head articulates with the body of the 
incus. The incus by its long process is 
attached to the stapes. The stapes by 
its foot-plate is inserted into the oval 
window, thus completing the junction 
between the membrana tympani and the 
internal ear. 

Causes of Ear-Disease in Children. 
— The commonest causes of aural disease in childhood are the acute exan- 
themata, acute and chronic catarrh of the nares and naso-pharynx, diph- 
theria, diseases of the heart, and hereditary syphilis ; while in older children 
typhoid fever has much to answer for. Measles and diphtheria together, 
however, do not affect one-quarter as many ears as scarlet fever. 

Malformations. — Shallowness of the niches of the round and oval 
windows, on the inner wall of the drum-cavity, favors a retrogression 
of swelling in the mucous membrane of these parts. A greater depth of 
these niches, especially in that of the oval window, where the stapes sits, 
is unfavorable for healing; and favors chronicitv of disease. Thus may 
be explained many cases of profound deafness, even deaf-dumbness, in 
children, without resorting to an hypothesis of disease in the internal ear, 
or labyrinth. 

In hydrocephalus the temporal bone is pushed doM'uward by the super- 
incumbent water, the external auditory canal being forced in the same 
direction. 

An arrest of development may occur in the middle ear, the external ear 
being normal ; and the reverse may also be found. 

In infancy and up to the fourth year (Huschke) a deficiency or a gap in 



Left Tympanic Cavity laid Open. ( Bur- 
nett.)—!, mastoid cells laid open ; 2, head of 
malleus; 3, malleus; 4, annulus tympanieus; 
5, membrana tympani ; 6, lower mastoid cells ; 
7, mastoid process ; S, the vestibule ; 9, stapes 
in the oval window ; 10, position of cochlea, 
removed ; 11, jugular fossa. 



4 DISEASES OF THE EAR IN CHILDEEN. 

the bone of the external auditory canal at the anterior lower wall may be 
found, closed, however, by connective tissue. Through this opening in- 
flammation may extend from the external ear, by ulceration of the skin, to 
the parotid gland and the lower jaw. Defects in ossification are frequent in 
the tegmen tympani, with normal dura mater, in the carotid canal, near the 
front part of the tympanic cavity, and in the facial canal. These explain 
the ready occurrence of facial palsy in otitis media. Defects in the bone 
are found also in the floor of the tympanum over the jugular fossa, in the 
rudimentary cortex of the mastoid, and in the squama. Inflammation may, 
through these deficiencies in the bone about the ear, be transmitted to the 
brain, inducing a fatal termination of an aural disease in a child. 

Hypersemia of the petrous bone occurs markedly in variola and in 
typhoid fever. The ear-disease so often following these maladies may be 
thus accounted for. 

Hyperostosis of the petrous boue may be the result of ossifying peri- 
ostitis in foetal life or in early childhood. It always leads to great deafness 
and deaf-dumbness. 

Caries, or ulcerative ostitis of Schwartze, attacks the petrous bone most 
frequently of all the cranial bones. It is usually the result of an acute or 
chronic suppuration of the soft tissues of the ear, which has extended to the 
adjacent bone. It is rarely the result of primary periostitis. Caries of the 
temporal bone often heals without much loss of hearing if the labyrinth has 
escaped the attack. Necrosis is much less common than caries. However, 
nearly the whole temporal bone may be thrown oft", and yet the patient 
survive. The fatal results of caries and necrosis usually are due to purulent- 
meningitis, abscess of the brain, phlebitis of the sinuses, with pyaemia, or 
to a combination of them all. Death sometimes results simply from oedema 
of the brain, caused probably by interference in the circulation by a remote 
phlebitis and embolism. It is now^ admitted that brain-abscess is the result 
and not the cause of aural necrosis.^ 

True tubercles are rarely found in the petrous bone, but they do exist, as 
shown by Zaufal. 

Malformations of the Auricle. — Complete absence of one or both auricles 
may be the result of arrested development. There may also be absence of 
parts of the auricle, or there may exist simply a microtia, the parts being 
perfect in form. Usually with great deformity of the auricle, malformations 
in the deeper parts of the ear exist, — e.g., atresia, stenosis, or absence of the 
meatus or the labyrinth. Such anomalies are referred by Virchow to dis- 
turbances in the closure of the first branchial cleft, and are often associated 
with cleft palate and unilateral atrophy of the face (Schwartze). Sometimes 
excessive development of the auricle is observed. 

Fistula auris congenita of Heusinger is not uncommon, and may be re- 
garded as a remnant of the first branchial cleft. It is characterized by a 

^ Schwartze, Pathological Anatomy of the Ear, p. 17. 



DISEASES OF THE EAR IN CHILDREN. 5 

small opening one centimetre above and in front of the tragus. Sometimes 
the opening is found in the lobule (Betz). The cicatricial depressions in the 
skin in the same region are also due to imperfect closure of the branchial 
fissures. These defects are sometimes associated with other auricular mal- 
formations and with fistulse in the neck. The fistula auris congenita some- 
times discharges a creamy matter containing pus. 

Inflammation and its Results. — Erythema, eczema, and intertrigo of the 
auricle are common in early childhood. The latter is usually seen behind 
the auricle. Gangrene of a spontaneous nature may be found in nurslings, 
but is not common (Schwartze). Syphilitic lupus, pemphigus, and congeni- 
tal ichthyosis are often seen in the auricle. In fact, all skin-diseases which 
affect the integument near the auricle may also affect the latter. Eczema is 
the most common affection of the skin attacking the auricle, both in the acute 
and the chronic form. If allowed to become very chronic, it may perma- 
nently thicken and discolor the auricle. One of the most annoying results 
of eczema of the auricle is the matting of the hair brought about by the dis- 
charges from the broken skin. This skin-disease is often due to disorders 
in the child's digestion, but in most cases the disease is greatly aggravated 
by the local irritation and interference from the patient's fingers, and the 
improper management of others. 

Very often wearing a cap leads to maceration of the baby's auricle and 
the side of the head behind it. Intertrigo is the first step, and then eczema. 
Even in this first stage, the parts should not be washed with soap and 
water, nor even with water alone. The parts affected may be smeared with 
bland sassafras or quince-seed mucilage, or, still better, sprinkled with a 
powder composed of equal parts of Hubbuc's oxide of zinc and starch. 
The pellicle, or crust, which this forms with the secretions from the ecze- 
matous skin, should be allowed to remain, as it protects the inflamed skin 
and favors healing. If the yellowish crusts of hardened serum get very 
thick, and must be re'moved, in the more chronic form, then soften with 
sweet oil, and gently remove them ; but avoid this in the acute stages. In 
acute eczema the skin must be protected as in burns. Adhesions between the 
auricle and the side of the head may be prevented by anointing the parts 
with sweet oil, cosmoline, vaseline, or lanoline. In children who are eating 
solid foods — in those from four to fifteen years of age — all highly nitro- 
genized foods must be avoided. In children of the age of ten years I have 
found chronic eczema of the auricle kept up by eating pies, cheese, sweets, 
and pickles. 

For the treatment of all other skin-diseases of the child's auricle the 
reader is referred to works on cutaneous diseases, — with this caution, that 
the various applications to the diseased skin of the external ear must not be 
allowed to clog the external auditory canal nor to run down upon the drum- 
membrane. 

Boxing the ears, pulling the ears, and swabbing the canal for imaginary 
wax and dirt must be most carefully avoided. Boxing the ears is apt to 



6 DISEASES OF THE EAR IX CHILDREN. 

produce rupture of the drum-membraue, by the force of the column of air 
driven suddenly against it. The mere rupture of the normal drum is not 
as serious an injury as many suppose, as merely the protector of the mucous 
lining of the drum-cavity has been ruptured, and not an important factor in 
hearing. Therefore, if this should occur, healing by first intention will 
generally ensue if nothing is dropped into the ear, and if the meatus is 
filled with cotton to prevent the ingress of air. The injury to hearing 
which may attend tiie rupture of the drum by a blow on the ear is not 
attributable to the rent in this membrane, but to a concomitant concussion 
of the auditory nerve. These important differential facts should be borne 
in mind in the consideration of the medico-legal aspects of rupture of the 
drum from a " box on the ear." It must also be shown in any asserted 
case of injury of this kind that the membraua tympani and the rest of 
the auditory apparatus were in good order before the blow, and also whether 
immediately after the injury any form of remedy was put into the ear by 
the patient, his friends, or his physician, as such treatment, by entering the 
drum-cavity through the hole, would certainly injure the middle ear, and 
cause the real malady in this important organ. 

Pulling the ears is open to nearly as much objection as " boxing" them, 
since the attachments of the auricle to the auditory canal are of such a 
nature ^ that traction upon them is communicated to the sensitive fundus of 
the canal, and even to the membrana tympani. Hence pain and injury are 
often the result of this rude and culpable manipulation of the ear. 

On the other hand, an excessive care of the ear, by washing away the 
wax from the meatus, often abrades and inflames the concha and the 
meatus. This should be avoided, as wax is not dirt, and should remain 
where nature puts it. The supei-fluous wax will roll out in little crumbs, 
every day or two, and removes itself by rolling into the concha. But more 
on this topic will be given when considering the affections of the external 
auditory canal. 

Wounding the cartilage in piercing the lobule for ear-rings sometimes 
occurs. This is due to the fact that this remnant of barbarous adorn- 
ment is relegated to jewellers for preparation, and, as they are ignorant of 
anatomy, they are not aware that sometimes the cartilage of the auricle 
extends far into the lobule. This is wounded in the piercing and usually 
causes severe inflammation. The ears had better not be pierced at all. 

With the exception of the auricle, the various parts of the auditory 
apparatus cannot be seen without special manipulation and the use of 
instruments. Hence a short consideration of the means of examining the 
auditory canal, the membrana tympani, and in some instances the middle 
ear, is now in order. 

1 Sexton and Pinkerton. 



DISEASES OF THE EAR IX CHILDEEX. 



Fig. 3. 





EXAMIXATIOX OF THE EAK. 

This can be done properly only by means of good reflected light, as it 
is neither easy nor satisfactory to examine the ear by direct rays of any kind 
of light, excepting those from an electric light held on the head by means 
of a forehead-band. Usually the reflected light of day or of a candle or 
lamp will be found amply sufficient. A speculum or ear-funnel is always 
necessary, even in infants. Down this speculum the light may be thrown 
or reflected from either a hand-mirror or a fore- 
head-mirror (see Figs. 3 and 4). 

The auricle must be drawn slightly upward 
and backward, while the speculum is directed 
downward and forward. Care must be taken 
not to push the speculum too far into the child's 
meatus, for reasons already given, — viz., the 
shortness of its auditory canal and the proximity 
of the membrana tympani 
Fig. 4. to the external meatus. 

Hence it is easy with a 
slender speculum to touch 
and wound the drum- 
membrane. The specu- 
lum must have a diameter 
of from two to three mil- 
limetres for infants, and, 
as a rule, no child's ear 
will take a speculum with 
a diameter of more than 
four or five millimetres. 

If the meatus and 
canal are filled with secre- Hand-mirror, 

tion, syringe these parts 
gently with warm water, or mop them out gently with absorbent cotton on 
a cotton-holder. After syringing the external canal, it should be mopped 
dry by means of absorbent cotton. 

Cerumen collects sometimes, but not often, in the meatus of children. 
Masses of epidermis and wax also sometimes collect here and form the so- 
called keratosis ohturans. It is said by Von Troeltsch that after scarlet 
fever the external auditory canal may become filled with desquamated epi- 
thelium. If so, syringing with warm water will remove the obstruction. 

At birth the so-called vernix caseosa fills the external auditory canal. 
The membrana tympani is at this time covered with a thick layer of epi- 
thelium or caul, and it seems to lie nearly horizotital, as the auricle and its 
fibrous canal are pushed upward on the infant's head, which brings the 
lower wall of the auditory canal nearly, if not quite, in contact with the 



Forehead-mirror. 



So 

y 



8 . DISEASES OF THE EAE IN CHILDEEN. 

membrana tympani. Hence to get a view of the membrana the eye must 
be directed upward, or the auricle must be pulled somewhat downward in 
order to straighten the canal. 

From this peculiar condition of the external ear in the new-born, it is 
probable that at birth all children hear poorly. This, however, is soon 
overcome by the lowering of the auricle and the external canal, and by 
the drying of the aforesaid matters in the canal and their exfoliation and 
dropping from the ear. They could be syringed out if necessary, which, 
however, is rarely the case. 

Syringing the Ear. — In syringing the ear of a child or an adult, but espe- 
cially in syringing an infant's ear, the nozzle of the syringe must be larger 
than the meatus of the ear, in order to prevent the entrance of the instru- 
ment into the canal. Hence the so-called ear-syringes which are made with 
a kind of nipple-like prolongation of the nozzle are especially reprehensible, 
as they can enter the meatus, and, from their length of half an inch or more, 
can reach and wound the membrana tympani. That this, and bruising the 
meatus by this means, are done, the author knows well. Hence the ordinary 
hard-rubber enema-syringe, !N^o. 2, the so-called male syringe,- is not only 
amply sufficient, but the only safe syringe within the reach of all. With 
this an ounce or two of warm water may be thrown into an infant's or a 
young child's ear, and the return current caught on a towel held closely 
under the ear. To hold a cup of any kind under the ear of a young patient 
will be found very inconvenient. 

THE AUDITOET CX^AL. 

Following the anatomical order, the next part of the ear after the auricle 
is the external auditory canal, or meatus. Its peculiar fibrous nature and 
freedom from bone in the infant have been described. Gradually, as the 
child grows, the outer surface of the annulus tympanicus, in which the mem- 
brana tympani is inserted, grows outward, and we find the indications of 
the formation of an osseous canal between the auricle and the membrana. 
This is not complete in development before adult life, though practically, 
and hence clinically, we must regard the child of five years as having already 
an osseous external auditory canal. The skin which is reflected from the 
auricle and lines this canal is exquisitely thin and sensitive, and is held 
closely to the bony canal by dense, tight fibrous tissue. In fact, the skin 
lining the external auditory canal is xevy much like a periosteum. 

Malformations may occur in the auditory canal, with malformations else- 
where in the head. The canal may be entirely absent, a congenital condi- 
tion, with entire absence of auricle and membrana tympanL Also a con- 
genital atresia caused by membranous or osseous tissue may be detected in 
some instances. Of course such cases are hopelessly deaf-mutes. 

Foreign Bodies in the ^ar. — This is a subject which is of great im- 
portance to the general practitioner, because he is generally the first to see a 
child who has got something in its ear. Afterwards, the specialist's aid is 



DISEASES OF THE EAR IN CHILDREN. 9 

invoked if, as is generally the case, the manipulatiou of the ear has been 
either useless or harmful. Let it be written at the outset in the most em- 
phatic manner that the mere entrance of a foreign substance into the ear 
is, in itself, of very little importance. In no case has injury to the child 
ever arisen from the mere presence of a foreign substance, like a bead, a 
seed, or a button, in its ear. It is the unskilful, rough, and lacerating 
efforts at its removal which have invariably produced the real injury. 

In addition to these statements, let it be remembered that whatever the 
child has put into its own ear, or had put there by other children, is cer- 
tainly small enough to come out, and can be removed easily if the methods 
are understood and there is no swelling of the meatus or caual brought 
about by previous 'rough efforts at removal. 

No child ever complains of pain from the entrance into the ear of the 
substances named, or of those similar in form and surface. A rough, jagged 
substance can never get into the ear, because the endeavor to put it there 
hurts and causes the child to resist, or desist. I have known beads and 
small seeds to lie for years in children's ears, without any discomfort. 

The first advice, therefore, to the patient — and the family physician too, 
unless he can make a diagnosis in the case — is to let the ear alone, when a 
child says there is something in it. Usually at this point the parents get 
alarmed, run for the first doctor, and frighten him into the belief that some- 
thing is in the ear. Instead of calming their fears by stating how harmless 
is the mere presence of such a thing in the ear, and assuring himself 
by careful examination with mirror and speculum w^hether there is any 
foreign body in the canal, he too often proceeds directly to probe the ear 
or to look in by direct light, and concludes by thinking that he sees 
something, and increases the alarm of parents and child by dwelling on 
the serious consequence of allowing anything to remain in the ear. He 
proceeds now from bad to worse by using improper instruments to remove 
sometimes an object which is not in the ear at all. In fact, no one but an 
aurist of experience should ever touch an ear with any kind of metallic 
instrument, even of the most delicate and special form. At this stage of 
the case we have sketched, if there is a small bead or seed in the ear, a few 
syringefuls of warm water will bring out the foreign substance. This I 
have done, even when the auditory meatus and canal were swollen and 
tender from antecedent rough handling on the part of others. 

First, then, do not be alarmed yourself, and you wall allay the fears of 
the jDatients' parents. 

Second, do not do anything but ascertain whether there is really, as 
asserted, anything in the ear. 

Third, do nothing but syringe the ear for the removal of the object if 
really there. 

Should you not be able to diagnose its presence, — ^and I trust you wall 
know enough to diagnose between a pearl button and the membrana tympaui, 
— invoke the aid of some one who you think can. Duty to yourself and to 



10 DISEASES OF THE EAR IN CHILDREN. 

your patient commands you to be quick to see your own ignorance in many 
cases, and you do the best service to your young patient by acknowledging, 
at least to yourself, your inability to make a diagnosis in a case of foreign 
body in the ear. You can never injure the patient by gently syringing 
the ear with warm water. But you dare not do more with your limited 
knowledge, without incurring the risk of doing the child irreparable injury 
— perhaps of destroying its life — by your mismanagement. I know many 
instances where the hearing- has been entirely destroyed and the child tor- 
tured with pain, not by the presence of the foreign body in its ear, but by 
utterly unjustifiable efforts at its removal by probes, forceps, etc., in the 
hands of those whose common sense should have taught them better. It is 
impossible for any one not a specialist to diagnose positively the presence of 
a foreign body in the ear, if it has gone beyond the meatus, and of course 
it follows that he is also unable to remove it, excepting by warm-water 
syringing. Therefore, I have given all the treatment necessary for the suc- 
cessful management of such cases by the general practitioner. If you can- 
not remove the foreign body by syringing, let it remain in the ear, until 
the patient can consult an aurist. No foreign body can ever reach the brain, 
unless pushed there by the hand of the surgeon. 

When roaches, fleas, or insects of any kind get into the ear, a few 
drops of sweet oil, or any fixed oil, will smother them, and relieve the 
suffering caused by their movements. The removal of the dead insect falls 
under the same form of proceeding as already given for beads, etc. Use no 
instruments ; for nothing worse than temporary deafness will result from its 
remaining in the ear, but death may result if the physician should forget his 
unfitness for such work and attempt its removal by picks, pincers, etc. The 
sooner this conservative proceeding is followed by the general practitioner 
in cases of foreign body in the ear of children, the sooner we shall ce^se to 
read of the disaster attending the entrance of a foreign substance into the 
ear, which in reality is a very trivial matter if not improperly treated 
at the outset. 

In some very rare instances maggots have been known to get into the 
ears of children affected with otorrhoea. If such an accident occur, a drop 
or two of chloroform or ether will destroy a maggot's life instantly, whereas 
syringing the ear with warm water only makes the maggot more lively and 
the pain in the ear more intense. 

Reflex Phenomena. — In rare instances epileptiform phenomena have 
arisen from the presence of a foreign body in the ear. Sometimes paretic 
symptoms have also shown themselves on the side of the body correspond- 
ing to the ear in which the foreign substance lies. Whenever such phe- 
nomena not otherwise easily explicable arise in children, the ears should be 
examined as the possible seat of the cause of irritation. Of course the 
line of action is plain if a foreign body is found in the ear : it must be 
taken out. But all the precautions already given as to this procedure must 
be carefully observed. 



DISEASES OF THE EAR IN CHILDREN. 11 

Wax in the Ear. — Wax, or cerumen, rarely accumulates in plugs in a 
child's ear to such an extent as to interfere with hearing. If^ however, 
such masses form, syringing with warm water is all that is required for 
their removal. All forms of spoons, picks, etc., will hurt the ear, and act 
just as unfortunately as in attempts to remove any other foreign substance 
from the ear. 

Accumulations of wax in the ear may be softened by instilling into the 
ear, a few times before syringing, five or ten drops of the following : 

R Sodii bicarb., gr. xx ; 
Glycerini, f^i ; 
Aquae, fgvii. 
Misce. 
S. — Apply warm to the ear. 

Now and then there are found in the ears of children from five to ten 
years old hard, leathery, or even horny plugs composed of laminae of epi- 
thelium with a little cerumen in the outer end, near the meatus. These 
plugs quite fill the canal and render the ear totally deaf. Their removal is 
tedious, and can be accomplished only after continued use of the above- 
named solvent drops and patient syringing. If this does not accomplish 
their removal, it must be done by means of special instruments under 
illumination from the forehead-mirror. It is needless to say that by this 
time the case should pass into the hands of one specially qualified to treat 
it. I have known the deafness and pain arising from the pressure of these 
hard plugs in the auditory canal to be treated for years as due to other 
causes, — of course, without benefit. Finally, when the true cause was found 
out by one able to make an examination of the ear and a diagnosis, restora- 
tion to hearing and health soon followed. 

Both these accumulations — of wax and of laminae of epithelium — often 
owe their beginning to the efforts of parents and nurses at cleaning the ears 
of children. It is a mistake to regard wax as dirt, and a greater error to 
make efforts at its removal from the auditory canal. Some Avax is needed 
for the protection and comfort of the ear, and the superfluous wax will roll out 
into the concha every day or two, and can be easily removed from that part 
of the ear. If, however, a swab or any form of spoon is used for removing 
wax from the canal, as much as, or perhaps more than, is removed by such 
implements will be pushed into the canal and gradually packed down upon 
the drum-membrane. At the same time more or less abrasion of the deli- 
cate skin of the canal occurs. When wax and pieces of epithelium are 
pushed down upon the drum, deafness is soon the result, of which the very 
young child is unconscious, the natural escape of flakes of dead skin and 
pieces of wax from the ear is interrupted, and as more epithelium is 
thrown off behind the mass the latter gradually grows to one of the afore- 
said keratosis plugs. Beneath these plugs sooner or later maceration and 
ulceration take place, polypi spring up, and the membraua tympani may be 
eroded and tympanic inflammation finally result from improper efforts at a 



12 DISEASES OF THE EAR IX CHILDREN. 

toilet of the ear. Furthermore, the presence of these plugs of wax and 
skin, when they have begun to press upon the skin of the canal and irri- 
tate the external ear and the membrana tympani, may induce epileptiform 
phenomena in any one, but especially in children. 

It is certainly wise, therefore, to refrain from any toilet of the ear, 
which is not only not required but may even lead to a direful train of 
phenomena. 

Aspergillus. — If the wax is removed from the external auditory canal, 
the fungus called the aspergillus, a variety of mould, may grow in the 
fundus of the ear upon the membrana tympani. The spores of the plant 
do not flourish in the presence of ear-wax, as I have tested by experiment, 
but readily enter the ear and grow upon any morbid secretion found there 
if the wax has been wiped away and if in so doing the patient or the at- 
tendants have abraded the skin and permitted the escape of a little blood 
or serum into the canal. This furnishes the fitting soil, and soon the spores 
of the aspergillus sprout from it, form a mycelial web upon the drum- 
membrane, and bring about a dermatitis of the fundus of the canal and the 
membrana tympani. 

The ear now becomes painful, deaf, and from it a watery discharge soon 
ensues. Syringing with warm water will generally remove the false mem- 
brane and the spores, after detachment sets in, which usually takes place 
soon after the discharge appears. In these cases, again, successful treatment 
depends much upon the correct diagnosis at the outset ; otherwise no treat- 
ment is of value. Any oleaginous or greasy application is injurious, be- 
cause it favors the growth of the fungus, and the ear goes on to a condition 
of painful eczema in little children, with many disagreeable symptoms from 
the nervous irritation so easily set up in the ear, and felt in the general 
nervous system. 

There are many drugs which have been cited as destroyers of the asper- 
gillus, but I have found only one that is prompt and painless as well as effi- 
cient, — viz., salicylate of chiuoline, one part to sixteen parts of boric acid. 
This powder should be insufflated into the ear after all the easily-detachable 
pieces of the false membrane have been removed by warm-water s}'ringing. 
Usually one application of this powder to the affected membrana tympani 
destroys the aspergillus and cures the disease. 

Otitis Externa Diffusa. — This name is applied to the diffuse inflammation 
attacking the skin of the auditory canal as a result of the irritation arising 
from the ingress of improper medicaments, cold air or cold water, from 
picking and swabbing the ear, and also from the continued presence of the 
fungus aspergillus. Direct violence, from putting snow in the ear in rude play, 
blowing into the ear, and subjecting the child to sudden changes of temper- 
ature, will also have to be held accountable for this disease, in many cases. 
It is a very painful affection, and, by its tendency to involve the subcuta- 
neous tissues and even the periosteal lining of the osseous part of the audi- 
tory canal, it assumes very often all the features of a periostitis. The skin 



DISEASES OF THE EAR IN CHILDREN. 13 

rapidly becomes red aud swollen, and, from its confined position in a carti- 
laoinous aud osseous canal, is thrown into several thick folds or ridges, 
which uniting in the centre of the canal soon obstruct all view of the drum- 
head and render the patient hard of hearing. Movement of the auricle 
by the hands of another becomes very painful at this point of the disease. 
Tinnitus is also complained of, as well as intense pain. Several days usually 
elapse, with all these painful annoyances to the patient, before secretion sets 
in. Then the skin often exudes, at first from several points, a bloody serum, 
followed in a day or two by a purulent discharge. The quantity of serum 
discharged in such cases is often very copious, whetting a number of towels 
or cloths in the course of twenty-four hours. Sometimes the inflammation 
may extend to the membrana tympani, and involve it, so that perforation 
ensues and mucus is found in the discharges of the ear. 

Treatment. — When seen in the first stages, while the skin of the canal 
is swollen and tender, the best treatment is to make one or two deep in- 
cisions, down to the bone if necessary, into the congested skin. This will 
often cut short the diseasec; but the method is painful. The next best 
means of relief will be to apply a dossil of cotton moistened wdth the 

following mixture : 

R Black wash, f^i ; 
Glycerin, f^i ; 

or with a fifteen-per-cent. solution of ichthyol in water. I have known 
each of these to abort both the circumscribed (furuncles) and the diifuse 
form of otitis externa. These applications usually control pain much 
better than morphine drops, cocaine, or atropine, which are in my experience 
nearly impotent to allay pain in such cases of earache. If, however, sup- 
puration is fully established, the ear must be gently syringed with weak 
salt-and-water, warmed, or with boric-acid solution, or with a two-per-cent. 
solution of carbolic acid, or with plain warm water, and then gently mopped 
with absorbent cotton ; and, if the acute stage has fully passed and the ear 
is no longer sensitive to touch, boric acid in fine powder, or boric acid seven 
parts and iodoform one part, may be insufflated. If the ear is thus cleansed 
once or twice daily while the discharge is copious, and then once a day or 
every second day as the discharge diminislies, the organ will soon heal. 
But all fats, oils, vegetable matters, and poultices must be kept away from 
the ear, at this time and at all others. They only macerate the tissues of 
the ear, promote granulations, and cause breaking down and sloughing of 
the fundus of the canal and the membrana tympani. 

As the discharge ceases, granulations or small polypi may be seen on 
the w^alls of the canal and on the membrana tympani, while the latter may be 
found perforated. The granulations, if not yet pedicellated, will generally 
disappear under the use of the powders named above, — under the so-called 
dry treatment. If they do not, they may be removed, under proper 
illumination of the canal, with forceps or snare. The perforation also 
generally closes under proper treatment as just marked out, and the hear- 



14 



DISEASES OF THE EAR IN CHILDREN, 



ing becomes normal. Unfortunately, as soon as the earache stops the ear is 
often neglected and allowed to remain filled with decomposing and irritating 
matter, until a chronic otorrhoea is established. 

Effect of Teething on the External Auditory Canal. — 
During teething the external auditory canal may become congested and 
painful. Not uncommonly the engorged vessels are relieved by an escape 
of pinkish serum, or suppuration may ensue, after considerable fretting or 
great crying on the part of the child. This crying is too frequently re- 
ferred to the gums, — which, in fact, are rarely the seat of pain. If the ear 
is found congested or inflamed by this cause, — the irruption of a tooth, — 
dry heat applied to the external ear of the little patient gives great relief 
and favors resolution of the congestion. The simplest, and often most effi- 
cient, means is a bottle of hot water held against or in front of the auricle. 

The effects of diseased teeth are often reflected upon the skin of the 
auditory canal and tympanic cavity of large children and adults. The reflex 
effect of dental irritation upon the drum-cavity and the membrana tympani 
of infants will be considered when discussing diseases of the drum-cavity 
in children. 

MEMBKANA TYMPANI. 

This part of the conducting auditory apparatus is of the same size in a 
child as in the adult. Its general appearance is represented in the accom- 
panying wood-cut (Fig. 5). This 
is the air-tight boundary between 
the auditory canal and the middle 
ear. It serves the double purpose 
of protecting the latter from the ex- 
ternal air, and of broadening the 
surface of the handle of the malleus, 
the great factor in the leverage of 
sound-waves upon the other ossicles 
and the fluid of the labyrinth. 

Congenital malformations of the 
membrana tympani are sometimes 
seen in early life, as a small opening 
in the upper part of the drum-mem- 
brane over the short process of the 
malleus, the so-called foramen E,i- 
vini. This is an arrest of develop- 
ment or a failure to close, like hare- 
lip, coloboma, etc. If such an open- 
ing in the membrana of a child is 
observed, care should be taken to 
avoid the entrance of Avater into the 
ear, as it might inflame the drum-cavity, should it find its way into this 
space. 




OiiTER Surface of the Drum-Membrane. 
Magnified Zy, times. (Politzer.)— 1, 1, the flaccid 
part of the drum-memhrane ; 2, the short process 
of the hammer-bone; 3. back fold of the drum- 
membrane; 4, the Ions limb of the anvil-bone, 
shining through the membrane; 5, 5, the true 
m.embrana tjTnpani, or membrana vibrans; 6, 6. 6, 
6, inner end of bony canal, forming frame for 
drum-membrane : 7, the pyramid of light ; 8, lower 
part of the hammer; 9, front fold of the drum- 
membrane. 



DISEASES OF THE EAR IX CHILDREN. 15 

Appearances. — Owing to the thick dermis of the membrane in chil- 
dren, their membranse rarely possess the lustre of the adult's drum- mem- 
brane. In general terms, it may be said that inspection of the membrana 
tvmpaui of an infant or very young child, by means of the so-called specu- 
lum or ear-funnel and a hand- or forehead -mirror, reveals at the bottom of 
the fundus a grayish or pearl-colored, circular, membranous diaphragm, 
with a lighter-colored ridge running in one of the radii from in front 
and above backward and downward. The latter is the handle of the ham- 
mer-bone. It terminates above at the so-called short process, a prominent 
knob, and below it ends at the umbo, or central depression of the mem- 
brana tympani. Backward and forward from the short process of the 
hammer, or malleus, to the periphery of the membrane run the so-called 
folds of the membrana tympani, and above these folds lies the membrana 
flaccida, or Shrapnell's membrane. This is free from fibrous tissue, and is 
composed of the skin layer of the drum-membrane and the mucous mem- 
brane of the attic of the drum-cavity, which here come together and form 
a loose membrane in the so-called segment of Rivinus. 

The pyramid of light, a reflection found in the lower anterior quadrant 
of the drum-membrane of larger children and adults, is not found always 
in infants. It is plainly visible, ho^vever, at two or three years of age. 

The membrana tympani forms an hermetical diaphragm between the 
external and the middle ear. It acts as a protector to the mucous mem- 
brane of the middle ear, and undoubtedly augments the leverage of the 
malleus, in the chain of ossicles, by its expansion about the handle of the 
hammer-bone, which is thus enabled to catch sound-waves which fall upon 
its comparatively broad surface. But, as perforation or even large destruc- 
tion in the membrane does not appear to affect the hearing in numerous 
cases, it cannot be considered a very important factor in the chain of sound- 
conductors. It probably acts as a supporter to the malleus and enables 
it to maintain itself from locking too firmly with the incus. 

Not only the cutaneous surface but also the mucous layer of the mem- 
brana tympani of a young child is thick and highly developed. Hence its 
vascularity is readily augmented by irritants from without and within, and 
a myringitis, or inflammation of the drum-membrane, is excited at this age 
more easily than in later life. 

Diseases. — The diseases of the membrana tympani may be named as 
follows : traumatic perforation, acute inflammation, chronic inflammation, 
with or without perforation, and myringitis from the growth of aspergillus 
in the fundus of the canal. Being composed of skin from the external canal 
and mucous membrane of the middle ear, it readily partakes of the afi'ections 
of these parts, but rarely is the seat of a purely idiopathic disorder. A 
strict myringitis is, in fact, very difficult to define, yet clinically it has 
practical existence. 

Traumatic perforation of the drum-membrane from " boxing" the ear 
has been considered under Injuries of the Auricle, to which the reader is 



16 DISEASES OF THE EAR IN CHILDREN. 

referred (p. 5). The other forms of traumatic perforation occurring in 
children are due to the accidental thrusting of slender objects^ like pencils, 
knitting-needles, pens, etc., into the canal and through the membrana. In 
addition to the wound of the membrana, injury may be done to the ossicula 
or even to the internal ear through the oval window, by the penetrating 
instrument. 

If only the membrana tympani is perforated, the same cautious pro- 
ceeding must be observed as to avoidance of putting anything into the 
canal, as was recommended when speaking of boxing the ear. At the same 
time the meatus of the canal must be protected by cotton, and the air thus kept 
from falling directly upon the exposed mucous membrane of the drum-cavity. 
If no traumatic inflammation ensue, the wound in the drum-membrane will 
heal, often in a few hours. If the penetrating wound has dislodged or 
injured any of the ossicula, a serious result may be looked for. And if 
it has extended to the internal ear, cerebral symptoms soon show them- 
selves, and are followed sooner or later by profound deafness. As rarely 
anything more than a perforation of the membrana occurs from the violence 
alluded to, it will not be necessary to refer to the graver complication of 
injury to the ossicula or the internal ear, except to say that, if it occur, 
only a skilled aurist can manage it. 

Sometimes the membrana tympani is ruptured by diving and by loud 
and sudden noises, and sometimes, though rarely, by coughing. 

The perforation looks like a red line, or a gaping slit, either before or 
behind the malleus. The latter is, as a rule, larger and more plainly visi- 
ble than the former. The perforation whistle can always be heard if the 
Eustachian tube is pervious. There is generally a little pain at first. 

Perforation of the Flaccid 3Iembrane. — Sometimes a perforation is de- 
tected in the flaccid membrane above the short process of the malleus, accom- 
panied by little or no discharge. This may be due to erosion, from a foreign 
substance in the external auditory canal. More frequently, however, such a 
perforation gives exit to a discharge of offensive pus, and indicates grave, 
purulent disease in the upper part of the drum-cavity, — in the so-called 
attic of the drum. This form of tympanic disease will be considered 
when discussing affections of that part of the ear. 



DISEASES OF THE MIDDLE EAE. 

Diseases of the middle ear are the most numerous of all aural diseases, 
are especially common in childhood, furnish most of the cases of so-called 
" earache" among the young, and lie at the foundation of nearly all cases 
of permanent deafness. 

Pathology of the Middle Bar. — We find here also congenital mal- 
formations, as, for example, an abnormally small tympanic cavity, absence 



DISEASES OF THE EAR IN CHILDREN. 17 

of the fenestrse, one or both, or contraction of them by hyperostosis. The 
ossicles of hearing may be absent, or abnormal in size. The stapes is said 
to be most frequently at fault. (Von Troeltsch.) ]\Ialformations of the 
middle ear are usually associated with malformations in the external ear. 

The Eustachian tube is rarely malformed. A mastoid cavity is found 
in children, but it is very small and its cortex is filled with natural de- 
hiscences. This grows until puberty, when it is fully developed (p. 2). 

The tympanic cavity of a new-born child does not contain air if the 
child has not breathed. It is not filled with mucus, but with a thick 
mucous membrane in a hyperplastic state. In the first years of life the 
middle ear is more disposed to disease than later. In early childhood the 
dura mater and the tympanic mucous membrane are more closely connected 
than in later life. This is effected by the direct tissue-circulation between 
these parts through the petro-squamous suture. Hence affections of one 
region influence the other. 

The middle ear is further inclined to disease because of the connection 
between the Eustachian tube and the naso-pharynx. The latter region in 
children is very susceptible to " colds," and these effects are easily commu- 
nicated thence to the middle ear. 

The naso-pharynx is very rich in blood-vessels and glandular substance. 
Lying between the pharyngeal mouths of the two Eustachian tubes is the 
so-called pharyngeal tonsil. These vascular and glandular structures be- 
come congested and abnormally active in coryza and in the exanthemata. 
Then the Eustachian tubes become closed, aeration of the drum-cavity 
ceases or is greatly impeded, a vacuum is formed in the tympanum, and the 
membrana tympani is pushed inward by the external air. Swollen palatine 
tonsils and naso-pharynx act in the same way, by inducing stasis of cir- 
culation near the Eustachian tubes, and thus maintain an irritation in this 
delicate region. 

Unimpeded nasal respiration is of the greatest importance, as thus aera- 
tion of the middle ear is maintained. The naris is often impeded for a long 
time before it is discovered, and the ear on that side becomes deaf before the 
cause is found out. The quality of the air respired is most important, as 
each respiration, swallowing, gaping, or sneezing forces air into the middle 
ear, if the Eustachian tubes are not tightly closed. If they remain closed 
long, extravasation occurs in the drum-cavity, which can, however, be re- 
moved by inflation or by paracentesis. When the nose is stopped, air is 
more readily forced from the naso-pharynx into the Eustachian tubes and 
middle ear than when the nares are free. The same condition prevails 
in expiration, coughing, or swallowing when the nose is stopped. Hence, 
when the child sucks the breast, swallowing with its nose stopped and its 
mouth closed by the teat induces in its middle ear what is known as the 
negative effect of aeration of the naso-pharynx, — viz., an exliaustion of air 
from the tympana ; the membranse are then drawn inward, causing subjective 
noises, discomfort in the ear, and even pain and deafness. 
Vol. IV.— 2. 



18 DISEASES OF THE EAR IX CHILDREN. 

The same condition of the nares which thus favors the entrance of air 
from the fauces into the Eustachian tubes may also favor the entrance of 
water. Hence vomiting, as in whooping-cough, may force the contents of 
the stomach into the middle ear, and cause otitis media. INIucus also may 
be thus forced into the Eustachian tubes and middle ear. 

Pus in the tympana of very young children (from two days to two weeks 
old) may be regarded as physiological and due to metamorphosis of the 
mucous cushion alluded to on p. 17. Dissections of the ears of children 
in their first year indicate that inflammation and exudation in the middle 
ear are very common in early life. 

The most usual form is the acute catarrhal otitis media, which may 
develop into the acute purulent, or may assume the form of chronic 
catarrhal otitis media without purulency. But no sharp line can be drawn 
between acute otitis media catarrhalis, which leads to rupture of the mem- 
brana tympani, and otitis media purulenta acuta, since when perforation of 
the membrana ensues some pus will be found in the discharge from the 
drum-cavity, though the quantity may be so slight and so evanescent as to 
permit the disease to be named a catarrhal one, with hypersecretion of mucus 
as its chief result. 

OTITIS MEDIA CATARRHALIS ACUTA. 

A very young child with a severe coryza and stopped nares is practically 
in the first stage of otitis media catarrhalis. Very often infants in this 
condition cry greatly, but the true cause of their discomfort is not known. 
Usually only one ear is attacked at a time. If a discharge of mucus or 
pus occur in a few days after the great crying-spell, then it is recalled that 
the earache may have been the cause of the child's lamentation. Very often, 
however, the pain in the early stage of catarrhal otitis media is not great, 
the congestion in the tympanum soon undergoes resolution, no discharge 
comes from the ear, and it is never known that the ear has been the seat 
of disease, unless the hearing is dulled by the attack and the child is old 
enough to permit detection of this altered function. This failure in hear- 
ing soon passes off, and many cases never shoAV any subsequent defects in 
hearing. 

On the other hand, with a coryza the child may soon begin to cry 
bitterly, and if a year old will put its hand to its ear, indicating the seat 
of pain. When able to speak, it will state that its ear aches. If suppura- 
tion does not ensue, the pain is relieved either by proper treatment or by a 
rupture of the membrana tympani and an escape of sero-mucus. 

Treatment. — When it is discovered that a child with coryza — for it is 
such who are usually attacked with this form of ear-disease — is suffering 
from earache, an endeavor should be made to free its nostrils and open the 
Eustachian tubes, for it is the swollen state of the latter and the vacuum 
formed thereby in the middle ear which cause the pain. If the tubes are 
not opened and air thus allowed to re-enter the tympanum, passive exuda- 



DISEASES OF THE EAR IX CHILDREN. 19 

tion ensues iu the drum-cavity aud soon leads to rupture of the drum or 
further complications in the middle ear. 

A camel's-hair pencil anointed with sweet oil or cosmoline may be passed 
gently backward towards the fauces, — not upward towards the frontal sinus. 
This will promote sneezing or coughing and tend to open the Eustachian 
tubes. Still better, inflation of the tympana by Politzer's air-bag should be 
done. With infants and very young children this is a simple and efficient 
operation. It is required simply to place the nose-piece in the nares, and 
inflate. No swallowing of water nor any other effort on the patient's part 
is required, as it generally cries, and this lifts the velum and shuts off the 
nares from the pharynx. A gentle puff from the air-bag will now usually 
inflate the tympana, aud often banish the earache. It must be done, how- 
ever, very gently in the acute stage, or the ear is made more painful by the 
concussion it receives. 

The pain may often be entirely relieved in a short time by the applica- 
tion of dry heat to the auricle or in front of the ear. A four-ounce bottle 
filled with hot water aud held to the aching ear I have known to relieve 
soon, and I have seen the child fall asleep to wake with no further ear- 
disease. A hot stone, a hot salt-bag, a hop-pillow, or a hot-water bag will 
accomplish the same. 

But beware of dropping anything into the ear in this stage of the disease, 
or of putting anything moist, reseml^ling a poultice, in or about the ear. 
If you doubt this, just apply to your own well ear any of the great variety 
of domestic remedies so often ruthlessly applied to an inflamed ear, aud 
you will perceive how quickly an acute otitis externa is excited, and 
how often this is added to the catarrhal inflammation in the middle ear. 
From my own experience I believe that very few catarrhal cases would 
ever pass into any very painful or serious stage if they were properly 
treated at the outset. It is certainly a fact that many are made worse by 
what is improperly and ignorantly put into the external ear. It does not 
reach the inflamed middle ear, but it inflames the external ear and increases 
the general congestion and pain in the organ. When I have seen a catar- 
rhal otitis media at tlie outset and have had the control of all the treatment, 
I have never known the inflammation to fail to yield promptly to treat- 
ment. On the other hand, I have seen what was at the beginning a simple 
and manageable disease turned into a very painful aud sometimes chronic 
one by improper treatment. 

Politzer's Jlefhod of Inflation : the Air-Douche. — As this method of in- 
flating the tympana is frequently mentioned in these pages, it should be 
said that it consists in blowing air through the nostrils into the naso- 
pharynx by means of a soft rubber l^ag made for the purpose, and held in 
the hand of the surgeon. (Figs. 6 and 7.) 

The nose-piece being inserted into one nostril, the other nostril is closed 
by pressure with the fingers of the surgeon. Then the ala of the nostril in 
which the nose-jjiece is, is gently pressed in front of the nose-piece, — not 



20 



DISEASES OF THE EAR IX CHILDEEX. 



down upon it. Then the patient, having previously had some water given 
him, is told to swallow. This act lifts the velum, shuts oiF the naso- 
pharynx from the pharynx, and opens the Eustachian tubes. If at this 



Fig. 7. 



Fig. 6. 





Politzer's inflation-bag. 



Application of the inflation-bag. 



moment air is thrown into the naso-pharynx by squeezing the air-bag, 
inflation of the tympana takes place. Instead of swallowing water, disten- 
tion of the cheeks with air will accomplish the same object. 

In very young children neither method can be used. Sometimes simple 
inflation by means of the air-bag, without any aid on the child's part, will 
force air into the tymjDana. Crying on the part of the child, by lifting the 
palate, will greatly aid inflation. 

In addition to the measures for relief already named, the child must 
be kept warm, and, if possible, in the same room, while the ear is at all 
painful or sore. The temperature of the room must not be below 70° F. 
The patient must be kept warmly dressed, and, if able to walk, must be 
kept ofP the floor, if the weather is cold. A mild sudorific may be given, 
and the food must be light. Such management will usually bring about 
resolution of the inflammation in the naso-pharynx and middle ear in the 
course of a few hours or a day. The dulness of hearing may remain for 
several days, and, if so, Politzer's inflation should be performed once a day 



DISEASES OF THE EAR IN CHILDREN. 



21 



Fig. 8. 



until the hearing improves, and less frequently as the hearing further 
improves. 

Sometimes, however, though the pain may be made to abate, the exuda- 
tion in the tympanum may be sufficient to cause rupture of the membrana 
tympani, and a yellowish mucus or muco-pus will be found 
escaping from the meatus into the concha of the auricle or even 
out upon the cheek. The disease has now become subacute, 
and may undergo a spontaneous cure in a few days, as evi- 
denced by cessation of the discharge and improvement in hear- 
ing, — ^the latter being discernible only in children who can 
talk, — or it may ])ass into chronic muco-purulent otitis media. 

The ear should now be mopped with absorbent cotton on 
the cotton-holder, or syringed with warm water, in order to 
remove all septic matter. After such cleansing one of the fol- 
lowing powders may be blown gently into the ear : finely-pow- 
dered boric acid ; or iodoform, one part, and boric acid, seven 
parts ; or boric acid treated with calendula or hydrastin. This 
treatment should be carried out every day if the discharge is 
copious, and less frequently as the discharge diminishes. 

It is well to state here that the boric acid is combined with 
calendula or hydrastin in the following manner. Mix tincture 
of calendula and boric acid together, minim for grain, and dry 
over water-bath. Then repowder the dried mass and mix it 
with one or two parts of boric acid as desired. The hydrastin- 
boric-acid powder is prepared in the same way. 

This treatment, if begun at once, will usually check the 
discharge from the ear in a week or two. If the discharge is 
neglected, a cure is effected much less rapidly. The cure is 
also hastened by the use of Politzer's inflation-bag. When the 
discharge has ceased, the membrana may still be found perfo- 
rated or it may have healed. The perforation in the mucous 
form of otitis media is usually smaller than in the purulent 
forms. 

The insufflation of boric acid in any of its combinations 
must not be done while the ear is tender or painful, as such holder' 
treatment undoubtedly increases the pain. Its use is indicated, 
however, as soon as the pain and soreness leave the ear. In fact, during 
the painful stage of otitis media the less put into the ear the better it is for 
the patient. Before the membrana ruptures or is incised by the surgeon, 
the local application of dry heat and the systemic treatment are all that can 
be done. Some have obtained good results from the administration of small 
doses of tincture of aconite root. Locally cocaine has been vaunted by 
some, but I have gained no aid from it in acute otitis media. As I have 
already said, the catarrhal cases, if seen soon and before various improper 
home remedies have been applied, yield to the application of dry heat to 



22 



DISEASES OF THE EAR IX CHILDEEX. 



the painful ear. The hot-water bag, the bottle filled with hot water, a hot 
stone in flannel, a hot sand-bag, a hot salt-bag, or a hot cushion of dry- 
hops will give the best aid and certainly do no harm. Moist applications 
in the form of poultices macerate too much and tend to harm the ear, just 



Fig. 9. 




Author's method of insufflating powder into the ear 



as they do when applied to the eye. One or two Swedish leeches applied 
near the tragus or beneath the auricle will often cut short an acute catarrhal 
process and prevent the formation of mu^o-pus. 

Paracentesis of the Jlembrana. — Even in the catarrhal cases of otitis 
media, paracentesis of the membrana may be performed, — though this oper- 
ation is more likely to be demanded in the purulent form of otitis media. 

Fig. 10. 




Paracentesis-knife. 



This must not be attempted, however, unless the surgeon can illuminate 
the ear with the forehead-mirror and conduct the delicate paracentesis- 
knife down to the bulging membrana. An incision may then be made in 
that part of the drum-membrane which is most distended by the products 
of inflammation in the drum-cavity. Such an operation usually gives 
speedy relief to the sufferings of the patient. 



DISEASES OF THE EAR IX CHILDREX. 



23 



OTITIS :media pueulenta acuta. 

In many instances the catarrhal form of otitis media cannot be relieved 
by any of the remedies I have indicated, but passes into otitis media puru- 
lenta. The pain in these cases will have defied all measures adopted for its 
relief, and terminates only when the membrana tympani ruptures sponta- 
neously or is incised by the knife. If pus forms, it can be seen behind the 
membrana, and the latter will usually bulge outward. It is this form of 
ear-disease which usually causes the distressing earache of children. In 
very young children the pain is so intense as to cause convulsions. In in- 
fants a coryza or teething will bring on this disease in the ear. In larger 
children the exanthemata, exposure to inclement weather, or ^^laying in the 
snow, or in summer excessive bathing in cold water or rapid cooling of the 
heated body by lying on the ground, will cause otitis media. 

In scarlet fever or measles this disease may come on insidiously without 
much pain. In such cases it seems to be of a chronic nature from the out- 
set. The perforation is usually large, as the membrana tympani sloughs 
easily in the exanthemata, espe- 
cially in scarlatina. ^^' 

The mode of reflex action 
concerned in the purulent otitis 
media of teething deserves our 
consideration. " A considerable 
portion of the blood-supply of 
the membrana tympani is derived 
from an artery that leaves the 
internal carotid in the carotid 
canal, and proceeds by a very 
short course directly to its desti- 
nation. Being thus closely con- 
nected with a large arterial trunk, 
this small tympanal branch (Fig. 
11 at 3) of the internal carotid 
arter}^ possesses very favorable 
circumstances for a speedy aug- 
mentation of its blood-supply. 
Xow, the nervi vasorum consti- 
tuting the carotid plexus at this 
part of its course come largely 
from the otic ganglion (Fig. 11 at 4). The third branch of the fifth nerve 
is cut through in the diagram to show this ganglion. On the other hand, 
the inferior dental nerve (Fig. 11 at 8) supplying the decayed tooth or 
gums, as the case may be, also communicates with this ganglion (Fig. 11 
at 4, 5). We thus arrive at a direct channel of nerve-communication, 
through the otic ganglion, between the source of irritation, the tooth, and the 




Neevous Connection between the Teeth and the 
Ear. (Woakes.)— 1, tympanic cavity : 2, auricular branch 
of auriculo-temporal nerve; 3, branch from the ganglion 
furnishing vascular nerves to the internal carotid artery 
and its branch the tympanic artery ; 4, otic ganglion ; 
5, branch from otic ganglion joining inferior dental 
nerve ; 6, middle meningeal artery ; 7. auriculo-temporal 
ner^-e; 8, inferior dental nerve to teeth and gums: 9, 
short tympanic branch of internal carotid artery. 



24 DISEASES OF THE EAR IN CHILDREN. 

vascular supply of the drum-head. The effect then of the irritating impres- 
sion proceeding from the decayed tooth or swollen gums will be to excite 
waves of vessel-dilatation in the correlated area, the drum-head. Its vessels 
now become largely distended, acute congestion is thus established, with its 
attendant stretching of the sensitive and tense tissue in which it occurs, and 
so occasions the pain experienced by the subject of these conditions. If the 
irritation be sufficiently prolonged, effusion into the tissues ensues, which 
under favorable circumstances will pass into suppuration and constitute a 
true otorrhoea. Owing to the free inosculation of the vessels of the drum- 
head with those supplying the tympanic cavity, it will not be long ere this 
region participates in the inflammatory process, so that this cavity may also 
become filled with pus or muco-purulent fluid." (Woakes.) Of course this 
accumulation must either escape by the Eustachian tube, as it can very 
easily in children, from the comparatively large size of this tube in them, 
or it ruptures the membrana and runs out at the external auditory meatus. 
Before discharge takes place from the drum-cavity, the pent-up matter may 
press upon the fenestrse and thence upon the contents of the inner ear, and 
may excite convulsions. 

Before suppuration ensues in the drum-cavity, inflammation may extend 
from the drum to the meninges of the brain, by the way of the petro- 
squamosal suture, through which a fold of dura mater dips into the tym- 
panic cavity and unites with the muco-periosteal lining of the latter. This 
fissure is wide and the portion of dura mater entering the tympanum 
through it is large in infancy. Towards adult life this fissure becomes nar- 
rowed or obliterated, but the vascular connection between the drum-cavity 
and the brain continues. 

Treatment. — Since otitis media purulenta begins as a catarrhal inflam- 
mation, the remedies suggested for the relief of the latter malady (pp. 18-20) 
may be applied in this. 

But I cannot too urgently object to the use of poultices or hot drops of 
tinctures and acids in this disease. By such procedure the ear is usually 
made w^orse, as an artificial otitis externa or a myringitis is brought on, and 
the original disease is masked. Very often this is the condition of the ear 
w^hen the physician is called to the patient, because of the indiscriminate 
use of a host of senseless household remedies. Examination of the mem- 
brana tympani reveals a bulging either below or above tlie folds, in the 
membrana flaccida, rarely in both regions. In either condition it is best to 
perform paracentesis. 

There are no " drops" which can relieve earache in children. If dry 
heat, inflation, or treatment of the inflamed nares will not do it, nor rest in 
bed in a warm room wdth antiphlogistic and sudorific treatment accomplish 
it, only the escape of pus, either spontaneously or by means of the para- 
centesis-knife, will give the desired relief. 

After the discharge of pus has set in, the ear must be gently mopped with 
absorbent cotton, once or twice daily, or oftener, to keep it clean and dry. 



DISEASES OF THE EAR IX CHILDREX. 



25 



Fig. 12. 



This is preferable to the syringe. If, however, the discharge is copious and 
tenacious, the ear may be syringed at the beginning of the discharge, but 
not as the discharge di- 
minishes. After the ear 
is cleansed, insufiSations 
of boric acid alone or 
of boric acid and iodo- 
form combined may be 
employed, if the ear has 
lost all pain and tenderness. If the 
discharge keeps up for a fortnight and 
is very purulent, the ear may be mopped 
with a two-and-a-half-per-cent. solution of 
carbolic acid, previous to the insufflations. 

The surgeon must be on the lookout for 
granulations and polypi. If the former ap- 
pear, the above treatment will often cause 
them to disappear; if not, they may be 
gently touched with as much fluid chromic 
acid as will cling to the end of a bare cotton- 
holder. If true pedicellate polypi form, 
either gentle torsion of the polyp by means 
of a i^robe, under perfect illumination, or 
snaring it with the polyp-snare, will remove the growth. 

CHRONIC PURULENT OTITIS MEDIA. 

Unless acute purulency of the middle ear stops spon- 
taneously in a few weeks or is checked by proper treat- 
ment in an equal period of time, the patient becomes the 
subject of chronic purulent catarrh of the middle ear. 

This disease is usually the result of neglect, and is 
easily established in the cachectic or debilitated. The 
majority of cases are the result of severe scarlatina. 
Measles and intense coryzas at the time of teething fur- Author's poiyp-snare. 
nish their share also. 

If the canal is examined, it will be found either partly or entirely filled 
with pus and, in the earlier stages, strings of mucus from the Eustachian 
tube. I would say here that a discharge from the ear, especially if a 
copious one, is prima facie evidence of the existence of a perforation in the 
membrana tympani. After this discharge is removed from the canal, either 
by syringing with warm water or by mopping with absorbent cotton, the 
membrana tympani may be seen. Inspection will reveal that the mem- 
brane is perforated, usually at one point only, and that in the lower and 
hinder part. The perforation is sometimes large enough to permit a view 
of the red mucous membrane of the inner w^all of the drum-cavity beyond. 




26 DISEASES OF THE EAR IN CHILDREN. 

Very often the entire membrana is gone, only the peripheral annulus tendi- 
nosus and the malleus being left. The latter is indrawn, and its lower end 
is seen lying against the promontory. If the perforation is smaller, the 
malleus will be seen to be entire and in normal position. The remnant of 
the membrana is then macerated, and in some cases denuded of its epithe- 
lium. In other cases the dermis of the membrane is intact, but thickened 
and white. If the perforation is large and extends far into the upper and 
posterior cjuadrant, the incus-stapes joint may be seen easily. Polypi are 
often found in this form of ear-disease, extending beyond the plane of 
the membrana tympani, outward into the external auditory canal. Their 
protrusion in this direction leads often to the idea that they are attached to 
the walls of the auditory canal ; but, in reality, they originate from the 
mucous membrane of the drum-cavity, either from that on the inner wall 
or from that on the inner surface of the membrana tympani. The lining 
of the auditory canal is skin, and not mucous membrane. Hence polypi 
do not readily originate from it. 

Treatment. — If in a case of chronic purulent otitis media a polypus is 
found, it should be extracted before any attempt is made at checking the dis- 
charge. In fact, a discharge cannot be checked while a polypus is in the ear. 
A polypus may be removed by delicate forceps, or it may be twisted off its 
stem by the use of forceps, but the surest way is to snare it off by means 
of the polypus-snare (p. 25). This instrument should be very slender, 
so that it can be passed down the canal to the polypus under the eye of 
the operator. This can be clone if the instrument is slender enough to per- 
mit plenty of light from the illuminator to pass into the canal at the same 
time. A fine brass piano-wire, or the fine brass wire used by saddlers, is 
better than steel or silver wire, because it is more pliable and the bright 
color enables the operator to keep sight of the loop which he is endeavoring 
to place over the polyp. After the polyp is removed from its pedicle, the 
latter should be touched with a minute quantity of fluid {i.e., deliquesced) 
chromic acid. Just as much as will cling to the end of a bare metal probe 
will suffice for the purpose of cauterizing the pedicle. The hemorrhage is 
inconsiderable in all cases. If neither the wall of the auditory canal nor 
the mucous membrane of the drum-cavity be touched, the patient will ex- 
perience no pain. In fact, as the polyp has no sensibility, if the parts 
named be not touched, the patient will not know that anything is being 
done to him. After the removal of the polyp and the cauterization of the 
pedicle the ear may be insufflated with finely-powdered boric acid, alone 
or combined with iodoform as previously suggested (p. 21). 

After the removal of a polypus from the ear the discharge usually stops, 
— sometimes even without further treatment. However, some form of 
treatment is usually demanded for a few weeks. If the discharge does not 
then cease, we may suspect that a concealed polypus exists in the upper 
part of the tympanic cavity, — the so-called attic. 

The best treatment for checking the discharge after the polyp is removed 



DISEASES OF THE EAR IN CHILDREN. 27 

is the dry form, by the powders named. Sometimes strong solutions of 
nitrate of silver may be required. Nothing weaker than fifty grains to the 
fluidounce of water will be of avail, and solutions of one hundred grains 
are often most efficient. These must be put into the ear by the surgeon, — 
not bv the patient or an attendant. It is not necessary to neutralize them 
by salt water. Let the ear be gently and thoroughly syringed with plenty 
of tepid water a few moments after the application has been made. If 
this treatment has not a decidedly good effect after two or three applications 
have been made, it should be discontinued, or stronger solutions tried, even 
up to saturated solutions. But, of course, these must be arrived at with 
caution : the last-named strength will be needed rarely. 

If fluid applications ai'e demanded instead of powders, alcohol stands 
first in the list, in the treatment of chronic purulent otitis media. This 
may be used in the form of spirits of wine, or of absolute anhydrous 
alcohol. An application of ten drops may be made once or twice a day, 
after the ear is cleansed either by absorbent cotton or by syringing. 

Solutions of sulphate of copper, one grain to the ounce of water, sul- 
phate of zinc, from one to three grains to the fluidounce, and nitrate of 
lead, ten grains to the fluidounce, will be found of value in checking the 
discharge. As, however, the disease does best under the dry treatment, all 
fluid applications are but second choice. But cases may present themselves 
in which the dry treatment cannot be carried out, and in such the fluid 
apj)lications I have named will be found of service. 

Granulations, with broad base, need not be cut or scraped away. They 
will generally disappear under the antiseptic and dry treatment. But no 
fluid application excepting alcohol will be of nse when granulations are pres- 
ent. In fact, the fluid treatment is contra-indicated when granulations are 
present, as moisture promotes their growth and development into polypi. 

Chronic PuRrLENCY of the Attic of the Ty^ipanum. — Chronic 
purulent disease in the attic appears under two forms : (1) in conjunction 
with chronic suppuration of the atrium, or lower and larger part of the 
tympanum, the latter being accompanied by perforation of the membrana 
tympani ; and (2) as a chronic purulent disease limited to the attic, the 
membrana flaccida, the part above the short process of the hammer, alone 
being perforated, the membrana vibrans, the part below the line of the folds, 
being intact and often normal in appearance. In the first case the discharge 
is copious, while in the second form it is usually scanty. 

The attic contains the head and neck of the malleus and the body of 
the incus ; its upper wall is the tegmen tympani, the boundaiy between 
the tympanum and the cranial cavity. It is therefore manifest that disease 
in this space threatens the meninges by extension through the dehiscences 
which usually exist in the tegmen tympani. A combination of the two 
forms — i.e., the coexistence of a perforation in the membrana flaccida wdth 
one in the membrana vibrans — is the rarest exception. The membrana 
flaccida is that part of the membrana tympani bounded above by the semi- 



28 DISEASES OF THE EAR IN CHILDREN. 

circular bony edge of the segment of Rivinus — i.e., the inner edge of the 
upper wall of the auditory canal — and below by the folds of the mem- 
brana and the short process. As it is composed of two layers only, — skin 
and mucous membrane, being devoid of fibrous tissue, — it is loose, and has 
received the name of flaccid membrane. It is also called the membrane of 
Shrapnell, after him who first described it. 

The second form exists rarely in children, but there is reason to believe 
that the first form, in which the atrium is also diseased, is often found in 
them. In such cases as the latter the incus is often partly or entirely de- 
stroyed by necrosis. The malleus also is partly destroyed in the handle, 
the upper parts alone remaining in union with the remnants of the mem- 
brana tympani. The stapes is usually intact, as it seems most resistant to 
purulent disease and necrosis. 

Treatment. — The first form of attic disease demands, in addition to 
the treatment already laid down for chronic purulency of the drum, a 
thorough drainage of the attic. This is best accomplished by removal of 
the remnants of the membrana tympani, the malleus, and the incus. The 
stapes should be left undisturbed. This operation of excision of the rem- 
nants of the membrana and ossicula auditus is performed with the patient 
under ether. The illumination of the ear is accomplished by means of an 
electric lamp arranged to be worn on the forehead. If the incus-stapes 
joint is visible, the latter should be separated from the former, by means 
of a knife specially devised for this purpose. If this joint is hidden by the 
still extant upper posterior quadrant of the membrana tympani, it should 
be exposed or sought for, by the excision of the obscuring part of the drum- 
membrane. If discovered by this act, the joint should be severed as stated 
above. The next step will be to sever the tendon of the tensor tympani 
muscle, by means of another form of knife, specially devised for this act. 
Then all remaining attachments of the membrana tympani to the annulus 
tympanicus should be severed by means of a blunt-pointed knife, when the 
malleus, being seized by delicate forceps or by a polyp-snare, can be lifted 
from the ear. The incus in these cases is generally destroyed by necrosis, 
but, if not, it can be removed by forceps, or by a hoe-like instrument if the 
ossicle has slipped high up in the attic. 

If we are dealing with the second form, — viz., one in which the per- 
foration is in the membrana flaccida only, through which the pus escapes, 
while the membrana vibrans is intact, — the procedure is a little different. 
In this form the incus-stapes joint is necessarily unexposed : at most, only 
the neck of the malleus can be seen. The first act, therefore, will be to 
excise the upper posterior quadrant of the membrana tympani and expose 
the incus-stapes joint. Then disarticulate these two bones, sever the tendon 
of the tensor tympani, and cut away all attachments of the intact mem- 
brana to the annulus tympanicus, by a circular cut embracing the entire 
periphery. The malleus, with the remnants of the membrana, can then be 
removed as stated above. 



DISEASES OF THE EAR IN CHILDREX. 29 

This operatioQ may be the only means of obtaining a radical cure in 
some cases of chronic suppuration in the attic.^ Much relief, however, and 
even long periods of immunity from the offensive purulent discharge, may 
be obtained by the use of various fluid remedies applied to the attic, through 
the perforation, by means of the tympanic syringe. The latter is a syringe 
holding about a fluidounce, to which is fitted a slender nozzle, which is in- 
troduced into the attic through the perforation. By this means the diseased 
cavity may be syringed with peroxide of hydrogen, and then by solutions 
of carbolic acid, sulphate of copper (gr. iii to fgi), alcohol, etc., those named 
being the preferable ones. 

Peroxide of hydrogen, having a peculiar affinity for albumen, breaks 
up pus as soon as it comes in contact with it, making by such action a 
copious foam. This not only is a great cleanser, but it reveals by this 
foam the presence of pus even in very small quantities. When the foam 
ceases to appear it may be concluded that all pus has been removed. 

Mastoid Disease. — Affections of the mastoid, being usually the result 
of chronic purulent disease in the tympanic cavity, may be considered at 
this point. 

For clinical convenience mastoid inflammation may be divided into : 

1. Periostitis of its outer surface. 

2. Congestion and inflammation of the mucous membrane lining the 
air-cells of the mastoid cavity. 

3. Caries and necrosis ; followed by thrombosis of the lateral and other 
sinuses of the brain, general embolism, pysemia, or cerebral abscess. 

The first form is not uncommonly observed as an attendant of acute 
inflammation of the middle ear, with consecutive inflammation in the exter- 
nal auditory canal. It may also appear during chronic suppuration in the 
tympanum. An abscess may form over the mastoid as a result of this peri- 
ostitis, and in a strumous diathesis caries of the outer table of the mastoid 
may be induced. This latter, asthenic form is characterized by its painless- 
ness ; the former, or sthenic type, by great pain. The asthenic form may 
occur as a sequel of diphtheria in children. 

When the sequestrum is found, it should be removed at once. Such a 
disease as this, occurring over the outer wall of the mastoid in a child, 
becomes of moment not only to the hearing but even to the life of the 
patient ; because in children there is much greater probability of an exten- 
sion inward of such a disease than there is of its passage outward, for the 
tissues over the mastoid in young children are much more resistant than the 
thin and somewhat cribriform outer table of their partly-developed mastoid. 
Sometimes that which appears to be an abscess pointing over the mastoid 
undergoes resolution by ordinary poultices. 

The sthenic variety of mastoid periostitis is characterized by pain and 



' See Schwartze, Chirurgischer Krankheiten des Ohves, and Samuel Sexton, M.D., Dis- 
-eases of the Ear, William Wood & Co., 1888. 



30 DISEASES OF THE EAR IX CHILDREX. 

tenderness in the mastoid portion, M'ith some redness of the skin. It may 
mislead the observer into the idea that it is inflammation of the mastoid 
cells. But the less deep-seated pain in the ear and head and the readiness 
with which the periostitis yields to leeching or a deep incision (Wilde's in- 
cision) will serve as diagnostic points. It must be borne in mind, however, 
that inflammation of the external periosteum may be associated with deeper 
inflammation in the mastoid cavity. This, however, is hardly the case in 
young children, as they do not possess largely-developed mastoid cells. 
Hence the second and third forms need not be expected in them. Yet 
chronic purulent inflammation of the drum-cavity is often followed in 
children by thrombus in the cerebral sinuses, general pysemia, and abscess 
in the brain. 

After a purulent inflammation has existed for some time in the middle 
ear, there may suddenly arise an acute and violent inflammation in the 
organ. This usually occurs after exposure to cold air or to a cold water 
bath, or after a blow on the ear. The first result of the engorgement of the 
vessels is a diminution or checking of the discharge. The pain is often 
severe, and of a throbbing or boring kind. Pain is often felt in the brow, 
in the parietal and in the mastoid region of the aifected side. Facial 
paralysis is quite a common occurrence in these forms of inflammation in 
the middle ear. It is due to pressure of the greatly-swollen mucous mem- 
brane or the inspissated pus upon the facial nerve through a dehiscence in 
its canal. The discharge, "\vhich had at first ceased, may now be renewed, 
though altered in quality, being thinner and very offensive. The facial 
paralysis is, however, by no means the worst symptom in such cases, as it 
usually disappears if the patient survives. A more alarming symptom is 
swelling and pain in the jugular region on the side of the affected ear. This 
symptom indicates involvement of the lateral and other sinuses of the brain, 
and is apt to be followed by embolism in various parts of the body. If an 
abscess forms in the mastoid antrum of a child, it will much more readily 
discharge itself through the thin, cribriform outer plate of the mastoid 
process and point in the soft parts of this region. 

Such a termination is a usual one in childhood. Cerebral abscess is a 
not uncommon result of chronic inflammation of the tympanic cavity with 
involvement of the mastoid. It is due to purulent absorption, as is shown 
by its occurrence sometimes on the side opposite the diseased ear. 

Treatment of Mastoid Disease. — Inflammation of the mastoidal peri- 
osteum will usually yield to the local abstraction of blood by means of 
leeching or a deep incision — down to the bone. The incision is to be kept 
open for a day or two. An artificial perforation of the mastoid cortex will 
rarely, if ever, be demanded, in children. When the abscess makes its way 
to beneath the skin and points over the mastoid, the treatment is the same 
as for an abscess in any other part of the cutaneous surface. In fact, if the 
chronic purulent disease of the drum-cavity were more frequently heeded 
and promptly received proper treatment, there would be no mastoid involve- 



DISEASES OF THE EAR IX CHILDEEX. 31 

ment in childreu. Even when it does appear, ordinaiy poulticing Avill 

often give desired relief in children, on account of the soft and open 
mastoid cortex in them. 



CHEONIC ISrOISr-PTTEULENT OTITIS MEDIA. 

The onset of this disease in childreu is usually insidious. Infants mav 
be attacked by it and their hearing greatly impaired before it is known that 
such a change has oc^jurred. After a severe cold in the head and an acute 
catarrh of the Eustachian tube, the mucous membrane does not regain its 
normal state, but remains in a condition of chronic inflammation, which 
gradually assumes the form known as hypertrophic catarrh. This may set 
in without much or any pain. If the child is an infant, it may be remem- 
bered that it once had a bad attack of " snuffles or a bronchitis," but it was 
not noticed to be deaf In an older child — one who has learned to talk — it 
will be observed that it does not hear well after a cold in the head. This 
may pass away, to return with another cold ; and at last it is observed that 
the child is permanently dull of hearing, and perhaps growing worse. If 
at school, it falls behind in its studies, or it is supposed, often very unjustly, 
to be heedless, and gets blame which it does not deserve. 

If in this early stage the ears, the nares, and the throat be examined, 
changes peculiar to the disease will be found to have taken jDlace. The 
drum-heads, the membranse, will be found more retracted than normal, per- 
haps less shining, and the color transmitted through them will be red or 
pink, from the congested mucous membrane over the inner wall of the 
drum-cavity. 

The nares will present at this time a swollen and red mucous mem- 
brane over the turbinated bones, and the respiration through them will be 
impeded. A more or less sticky and copious discharge will come from the 
anterior nares and also flow backward into the fauces. 

The mouths of the Eustachian tubes will be found swollen and closed 
and blocked by mucus. The fauces are not always affected, like the nares 
and the Eustachian tubes, but usually they present a follicular pharyngitis 
and a swollen velum palati. 

If these conditions of the nares, Eustachian tubes, and middle ears have 
been present for several months, the little patient may have had attacks of 
not severe earache, or at times may have complained of sharp darts of pain. 
The child now breathes through its mouth and presents the verv injurious 
condition known as " mouth-breathing," the nares having nearlv ceased to 
do their usual work, and the alse being collapsed, giving the nose a pinched 
look. The hearing may now have become very much reduced and lead the 
parents to seek medical aid. Children five years old or more will often 
complain of subjective noises in the ears. By the repetition of isolated 
words, like "man" or " pin," or " four" or " more," it will be found that the 
hearing is reduced to a few feet or even inches, in serious cases. The con- 



32 DISEASES OF THE EAE IX CHILDREN. 

sonant sounds are lost first, the patient saying " tin" for " pin" when tested. 
A watch is a poor test, and I never employ it. The tuning-fork or a 
small music-box is much better as an aerial test. But the best test is the 
voice, in speaking words, as I have just indicated. 

If the nares are badly impeded, the words with nasals in them will be 
mispronounced, as the nasal resonance is cut off: e.g., the word "nose" will 
be pronounced " doze." 

Many cases of deaf-muteness arise in this way. The infant has a chronic 
aural catarrh, the process being identical with that in an adult. In the infant 
the process is not recognized until a year or two after its inception, when 
the child should begin to talk. Inspection reveals all the symptoms of 
chronic aural catarrh, but too often when all attempts at restoration of 
hearing are in vain, because the thickening of the membrana tympani, and 
more especially the sclerosis in the drum-cavity and in the joints of the 
ossicles, have become indelibly fixed. 

Many cases of deaf-dumbness are supposed to be congenital. More 
than half have really become such after birth. Perhaps not more than 
twenty-five per cent, can be justly called congenital. The majority certainly 
originate from diseases occurring after birth, in early childhood, and those 
occurring in early infancy are doubtless due in many cases to an insidious 
chronic aural catarrh, especially when no other distinct and probable cause 
can be assigned for the deafness. 

There seems to be some tendency to transmission of chronic catarrh of 
the middle ear from parent to child. When a deaf parent seeks advice 
regarding a child with catarrhal deafness, the prognosis is always less en- 
couraging. There is in such cases a transmission of the tendency for the 
nares and Eustachian tubes to assume a hypertrophic catarrhal condition, 
just as in some families there exists the tendency to catarrhal diseases 
of the bowels or of the lungs. 

The cerumen of the auditory canal is diminished in quantity and some- 
times brittle in quality in the early stages of chronic aural catarrh. 

The membrana tympani, as stated, undergoes changes in color and tenu- 
ity. Instead of a thickening there may be a thinning of the membrane, 
especially if there is a tendency to ozsena in the case. The color of the 
membrane often appears red, from the transmitted tint of the congested 
mucous membrane beyond. Calcareous spots are rarely found in the mem- 
brana tympani of a child affected with catarrhal deafness. 

The position of the membrana tympani changes, from the retraction it 
undergoes, after the catarrhal disease has affected the middle ear for some 
time. The malleus then appears foreshortened perspectively, and the short 
process seems unusually prominent. The manubrium of the malleus is not 
only drawn inward, but is pulled upward and backward, and, the curves of 
the membrana being thus altered, the pyramid of light, normally found in 
the antero-inferior quadrant, is either thrown upward in the anterior half 
of the membrane or disajjpears altogether. In fact, the normal pyramid 



DISEASES OF THE EAR IX CHILDREN. 33 

of light is usually one of the first features of the membraua to change in 
chronic aural catarrh. 

The manubrium of the malleus not only is indrawn in this disease, but 
it is rotated about its long axis, so as to pull the posterior half of the drum- 
head into greater prominence and to drag the anterior half into a greater 
depression. This is seen, however, only in older children and in adults. 

The Pharynx and Nuso-pharynx. — In children the moist form of hy- 
pertrophic catarrh is usually met, in which the uares, the pharynx, and 
the naso-pharyux are in a state of hypersecretion. The tonsils are usually 
enlarged, the nares impeded, and mouth-breathing is going on. If the case 
has assumed the atrophic state (ozfeua), the secretion of all these parts will 
be found scanty, and the mucous membrane dry and covered with scales 
of inspissated mucus and pus. In these cases the mucous membrane of 
the posterior pharyngeal wall looks as if varnished, the turbinated bodies 
are atrophied, the space in the nares is thereby increased, and the nares, 
not being able to clear themselves by normal respiration, are filled with 
decomposing and highly malodorous scales of dried mucus and pus. 

In some instances the velum palati shows a peculiar paresis if the case 
is at all chronic. The uvula then, instead of hanging in the median line, 
is drawn towards one side. This latter is found to be the side of the better 
ear, because the catarrh has not yet weakened the muscular structures of the 
velum- and the Eustachian tube on this side. The loss of normal mobility 
in the velum is further seen when the patient is told to phonate the sound of 
broad a. Then the velum and uvula, instead of rising quickly to shut off 
the lower from the upper pharynx, will fail to perform this act as quickly 
or as well as the normal organ. 

When the child blows its nose or when its Eustachian tube is artificially 
inflated, it often complains of cracking in the ear. This is caused by the 
air thus forced into the tube forming bubbles with the mucus. The mucous 
membrane of the nares and naso-pharynx may become very much congested 
and swollen, and so irritated thereby as to puff up and close the mouths of 
the Eustachian tubes, causing vertigo and faintness, if it is subjected to 
any irritant. 

Adenoid growths often occur in the naso-pharynx in northern and 
stormy latitudes. These growths are benignant in nature, are more or less 
leaf-like and conical in form, and are usually placed high in the pharynx. 
They are friable, and hence bleed easily. Their height or length rarely 
exceeds three centimetres, and their thickness varies from a few lines to one 
or two centimetres. These growths interfere not only with normal respira- 
tion and enunciation, but also with the normal ventilation of the Eustachian 
tubes and the tympana. The pharyngeal tonsil, situate in the vault of the 
naso-pharynx, often becomes enlarged in children, and is productive of 
chronic catarrh of the naso-pharynx, Eustachian tubes, and middle ears, 
with resultant hardness of hearing. 

Causes of Chronic Catarrh of the Middle Ear. — Very few parents 
Vol. IV.— 3 



34 



DISEASES OF THE EAR IN CHILDREN. 



Fig. 13. 



can assign a satisfactoiy cause for chronic middle-ear catarrh in their chil- 
dren. Chronic cold in the head, or frequent colds in the head, are un- 
doubtedly the fundamental cause of such chronic catarrhal deafness in chil- 
dren. Chronic aural catarrh is often found associated with and doubtless is 
aggravated by chronic catarrhal diseases in the mucous membrane elsewhere : 
by phthisis, by hereditary syphilis, by continued fever, by all eruptive 
fevers, and by eczematous conditions of the general integument. Whooping- 
cough and mumps are often followed by chronic deafness. After these two 
diseases, however, there is reason to believe that the auditory nerve is often 
primarily aifected. It has also been observed that the children of Anglo- 
Saxons born in tropical countries seem specially liable to chronic aural 
catarrh. 

Treatment of Chronic Catarrhal Otitis Media. — The treatment of 
this affection of the ear will depend upon the form of the disease in the 
case presenting itself. It must first be decided whether the 
disease partakes of the hypertrophic nature or of the atro- 
phic. The treatment for the first is very different from 
that demanded by the latter. Let it be said at the outset 
that the nasal douche should never be used. 

If the patient is an infant, it will not be easy to deter- 
mine the degree of deafness. If able to talk, the patient's 
hearing can easily be determined, as already shown on p. 31. 
Let us suppose we are confronted by a case of the hyper- 
trophic form of catarrh of the nares, naso-pharynx, and 
middle ear. The membrana tympani must be examined, 
after the hearing is tested ; then the nares and naso-pharynx, 
as far as is possible in young patients. We must note 
whether the turbinated bodies are in the first and active 
stage of hypertrophic catarrh, or whether a sclerotic and 
contracted stage has been reached. The condition of the 
fauces must also be noted, as well as the state of the tonsils. 
If a hypertrophic catarrh of the nares and naso-pharynx 
in the active, secretory stage is found, we may spray the 
nares and naso-pharynx with a solution of sulpho-carbo- 
late of zinc, three grains to the fluidounce of water, with a 
fluidrachm of glycerin. Or we may employ a spray of a modified DobelFs 
solution, consisting of the following : 

R Sodii bibor., 

Sodii bicarb., aa gr. ii ; 
Acid, carbol., gr. i ; 
Glycerini, f^ss ; 
Aquse, {^ i. 

Another excellent spray is obtained by using a solution of iodide of zinc, 
two or three grains to the fluidounce of water. 

These solutions are most easily and very efficiently atomized by using 




Bivalve specu- 
lum for examin- 
ing the anterior 
nares. 



DISEASES OF THE EAR IN CHILDREN. 35 

what is known as the Magic Hand-Atomizer No. 2, made by the Davol 
Manufacturing Company, of Providence, Rhode Island. There are, how- 
ever, numerous forms of hand-atomizers wliich act perfectly well. 

After the application of the watery spray it is advantageous to spray 
into the nares some liquid albolene. This is especially necessary in cold 
weather if the patient is likely to be exposed soon to the open air. 

If a more advanced stage of catarrh of the naso-pliarynx and middle 
ear has been reached, and there are evidences of sclerosis in the mucous 
tissues, a more stimulating spray may be employed. In my opinion, we are 
at this stage well served by a spray of the following : 

R Listerine (Lambert's), f^ss; 

Aquae, f§iv. 
Misce. 

Or 

K; Acid, boric, gr. x; 
Glycerini, f^i ; 
Aquse, f ^ i. 

Misce. 

It may be said, however, that in children the active secretory stage, with 
puffed and red turbinated mucous tissues, is much commoner than the pale, 
contracted, sclerotic form. 

The fauces will usually be benefited by the treatment applied to the 
nares, because some of the medication reaches these lower parts, and also 
because, the nasal respiration being improved by the nasal treatment, the 
child does not breathe through its mouth as much as previously, and the 
fauces thus escape the irritation of direct mouth-breathing. 

After the application of spray to the nares, the Eustachian tubes and the 
tympana should be inflated by the air-douche, accprding to Politzer's method 
or its modifications. This is the only form of inflation of the middle ear 
practicable in children, and, fortunately, no other is needed. 

If the patient be an infant, we have only to insert the nose-piece of the 
inflation-bag into one naris, and, with the two fingers of the left hand, gently 
compress the other naris and the ala of the one in which the nose-piece is 
(see p. 20). A moderate compression of the inflation-bag, in the right hand, 
will usually suffice to send air into the tympana. If the child cries, the 
velum is elevated and cuts oif the naso-pharynx from the pharynx, thus 
facilitating the inflation of the tympana. In larger children this is readily 
brought about by asking them to swallow a little water, previously taken 
into their mouth, at the moment we desire to inflate, or by telling them 
simply to distend the cheeks, — according to the suggestion of Dr. Holt, of 
Portland, Maine. If this is done gently and deliberately, the child will not 
be hurt and will not resist the surgeon's subsequent efforts for its relief. 

Here let it be said that no applications made to the external ear and the 
outer surface of the drum-membrane w^ill do any good in chronic catarrh 
of the middle ear. 

Excision of the tonsils is not demanded as an aid to the cure of chronic 



36 DISEASES OF THE EAR IX CHILDREN. 

catarrhal deafness. Applications of iodine and glycerin, equal parts, may 
be of value as tending to diminish the size of the tonsils. If follicular 
pharyngitis is present, applications of tincture of chloride of iron and 
water, in equal parts, may aid. 

Treatment of the Atrophic Form. — If we are called upon to treat a case 
of deafness dependent upon or associated with the atrophic form of naso- 
pharyngeal catarrh, the local treatment must be a stimulating one. This is 
accomplished by spraying the nares with a solution of iodine and carbolic 
acid, known as Boulton's solution, or with a solution of bicarbonate of 
sodium and biborate of sodium, of each half a drachm, to four fluidounces 
of listerine. 

In larger children with well-marked ozsena, there may be employed a 
spray of thymol, from half a grain to a grain to the ounce of water. 
Some alcohol may be required to make a perfect solution of this last-named 
drug. Its application stings a little, but this is allayed by spraying with 
fluid albolene, which should always be done after each act of spraying the 
nares and naso-pharynx. After the nares have been treated as explained, 
the tympana should be inflated. 

This treatment which I have sketched for the various forms of naso- 
aural catarrh, if applied properly and in time, will rescue an infant from 
the onset of deaf-dumbness, as set forth on p. 32. 

Deaf- Muteness. — If the chronic aural catarrh productive of deaf-dumb- 
ness in an infant were discovered in time, it could, as I have observed, be 
cm'ed, or sufficiently alleviated to prevent the child from being a mute. 
But if the case gets no treatment until the child is two years of age, its 
deaf-dumbness is incurable. 

When chronic aural catarrh occurs in children who have already learned 
to talk, thev should be encouraged to go on talking and not to make signs. 
Young children from three to five years of age will stop talking if they 
get deaf. They must now be forced to go on talking, while being treated 
for their chronic catarrhal deafness. If this is in part or entirely curable, 
they will retain their speech ; but they must be carefully watched, to see 
that they do not begin to make signs or mispronounce words. If their deaf- 
ness continues, they may nevertheless be rescued from being mutes by the 
precautions I have named as to their continued practice in the use of speech. 

The same care in exercising their speech must be given to young chil- 
dren who become deaf from diseases of the internal ear, like that occurring 
in cerebro-spinal meningitis, in mumps, and from blows or falls on the head. 
These forms of aural disease will be considered farther on in this article. 

Great assistance in making the child hear, and thus teaching it to per- 
fect its power of speech, and also to retain and improve its hearing, can be 
gained by the employment of either a good tin ear-trampet or, what is in 
my opinion still better, a Maloney otophone.^ This latter instrument con- 



1 Made by J. A. Maloney, "Washington, D.C. 



DISEASES OF THE EAR IX CHILDREN. 37 

veys speech to the deaf ear not only with the most ])ower, but also with the 
greatest purity of soimd, because it is free from unpleasant resonance and 
the interference of sound-waves. Furthermore, it has the very good feature 
of not being inserted into the meatus, but its aural end is provided with a 
disk-like expansion three inches wide, which is held against the auricle, and 
therefore does not cause pain in the ear. If a child retains any hearing, 
this will be improved and the child's speech developed by the intelligent 
use of the above-named instrument, to convey the words of a parent or 
teacher to its ear. 

Adenoid growths and enlarged pharyngeal tonsils, as described on p. 33, 
may demand removal by crushing, evulsion, or cauterization. It should be 
borne in mind, however, that these enlarged glands and adenoid bodies 
undergo a spontaneous retrogression towards puberty, and therefore, unless 
they are productive of great aural irritation and deafness, a conservative 
course of treatment should be pursued, and violent surgical interference in 
the naso-pharynx avoided, for such irritation of itself may set up an acute 
otitis media and aggravate, rather than ameliorate, the condition of the ears. 

Earache and Chronic Catarrh of the 31iddle Ear. — I am often asked. 
What should be done for earache ? As earache is commonly due to subacute 
attacks of catarrh in a child who is the subject of chronic catarrh of the 
naso-pharynx, I will try to answer the important question here. In all cases 
of earache the j)roximate cause should be determined, as well as the seat of 
the inflammation. Sometimes earache is due to a myringitis, the middle 
ear being very slightly or not at all implicated, as shown on p. 15. But most 
cases are catarrhal, and a child who has one attack of earache is very apt to 
have another, unless the nares and naso-pharynx are treated, and the child 
is kept from imprudent exposures to bad weather and wet feet in winter- 
time and from cold bathing and exposure to draughts of air in summer- 
time. If, however, a child has earache in spite of all that is done for its 
nares and middle ear, it should at once be housed, or even kept in its room 
and in bed if the pain is severe or long continued and there are symptoms 
of an acute " cold." Nothing should be dropped iuto the ear, for that is 
generally worse than useless : it always irritates the inflamed tissues. 

The bowels should be in a normal condition. If confined, a laxative 
or a purgative may be given, though this is not imperative unless the con- 
stipation is excessive. If the child is feverish, a mild febrifuge should 
be given. If the child seems to have simply a grumbling pain in the 
ear, in addition to keeping him in the house or in a warm room, dry heat 
should be applied to the painful ear, as set forth on p. 19. If in spite of 
this treatment the pain grows worse, the local abstraction of blood may be 
resorted to. But, as I have already stated, if the ear is not improperly 
treated by various drops at the beginning of the pain, which invariably 
make it worse at last, the very simple plans I have given, if promptly 
pursued, will give relief. 

At the beginning of an earache in a child who is already the subject 



38 DISEASES OF THE EAR IN CHILDREN. 

of naso-aural catarrh, an inflation of the tympanum, by Politzer's or other 
methods, will give relief by opening the middle ear and overcoming the 
retraction of the membrana tympani. 

Hygiene of the Ear. — Prevention of earache and further ear-disease, in 
such cases as I have described, is far more valuable than any attempts at 
cure, just as it is elsewhere in the body. A child who has once been the 
subject of an earache from catarrhal causes has received a valuable warn- 
ing ; or, at least, its parents have. 

Of course its nares and naso-pharynx must be carefully watched and 
treated until normal respiration through them is established and mouth- 
breathing prevented. A mouth-breather is always threatened with earache 
and deafness. Such a child must have plenty of exercise in the open air, 
must not be in a badly-ventilated school-room, nor must its study-hours be 
as long as those of the child free from such defects. 

Its underclothing must be of wool — all wool, not merino — at all times 
excepting the very hottest M^eather. Even at such time, if it can endure 
very thin w^ool, so much the better. But, as children are very active even 
in summer-time, they may be permitted to wear merino at that time. The 
feet and ankles must always be kept dry. 

In summer-time cold-water bathing should be indulged in with the 
greatest caution, while diving must be most strictly prohibited. Bathing 
in the tub in winter-time must be clone not too frequently, — once a week is 
enough for cleanliness, — always in a warm room (not lower than 70° F.), 
and preferably just before going to bed. If the hair is washed, as it often is 
in girls, it must be carefully dried with a towel, — not before a fire nor an 
open window, — and it would be safer to remain in the house the rest of the 
day. A fire is too heating and congesting, and a draught from an open 
window is of course very liable to cause a cold in the head, even in 
summer-time. 

The sleeping-apartments should be well ventilated, but no draught 
should be felt blowing on the head at any time of year. When in a per- 
spiration, the greatest caution should be exercised at all seasons of the year 
regarding cooling. The child should be taught that this should never be 
done in a draught nor rapidly in any way. 

In regard to blowing the nose, as it is termed, I would say that the 
nose should never be blown violently, but rather wiped, and sneezing should 
always be suppressed as far as possible, because both of these acts when 
done forcibly tend to further congest the nares and naso-pharynx and make 
the catarrh worse. I am sure many a so-called cold in the head could be — 
in fact, has been — prevented by avoidance of violent sneezing and blowing 
the nose at the beginning of the irritation. Hence catarrh snuffs and all 
forms of catarrh remedies of a sternutatory nature should be most care- 
fully avoided by those afflicted with a catarrh in the nares or ears. 

The shoes and clothing, like trousers in boys and skirts in young girls, 
should not become damp. But if these get wet from unavoidable exposure, 



DISEASES OF THE EAR IN CHILDREN. 39 

tliey should be taken off and dried as soon as possible. AVet feet are 
esjjecially injurious to the fauces, nares, and middle ears of children. 

Mouth-breathing in children must be stopped as soon as possible. lu 
those who are six years old and over it is often merely a habit, originating 
in past " colds in the head." In such cases an exercise of their volition will 
overcome it in the daytime and tend towards correcting it when they are 
asleep at night. All such efforts on the patient's part will be furthered by 
treatment of the nares by the remedies suggested for chronic hypertrophic 
and other forms of nasal and naso-pharyngeal catarrh. The nasal douche 
should never be used. The reader is also referred to the part of this work 
having especial reference to nasal and pharyngeal diseases and their treat- 
ment. 



DISEASES OF THE I^TEEJSTAL EAR 

By the internal ear is meant the so-called labyrinth, composed of the 
vestibule in the middle, the cochlea in front, and the semicircular canals 
behind. These parts are all interconnected. The auditory nerve sends 
branches to all three of these divisions of the labyrinth, but most gener- 
ously to the cochlea. The nerve-filaments in the semicircular canals have 
not been traced beyond the ampullse. In the vestibule they distinctly sup- 
ply the sacculi, the chief soft contents of that part of the labyrinth which 
is nearest the conductors of sound, being just behind the foot-plate of the 
stapes, where it is received into the oval window. The round window is 
practicaUy the distal boundary of the cochlea, while the oval window may 
be considered the point of the initial impression made on the endolymph 
in the labyrinth by the oscillations of the conductors of sound-vibrations, 
the ossicula auditus. 

These labyrinth structures and their mechanism are extremely delicate 
and susceptible of derangement by force from within the cranium and also 
from without. Many of the processes of disease in the internal ear have 
their origin in catarrhal diseases in the mucous membrane of the middle ear. 
The vascularity of these two parts is intimately and directly connected, 
and hence a morbid process in the middle ear — the part of the ear most 
likely to be primarily affected — is very easily communicated, by vascular 
changes, to the labyrinth. 

The deafness in such cases is slow in its approach, but permanent and 
incurable. Such are the forms of deaf-dumbness from chronic catarrh of 
the middle ear (see p. 32). 

In other instances the disease of the labyrinth originates within that 
cavity, and in such cases the affection is characterized by sudden and per- 
manent deafness. The cause of this form of labyrinth-disease is either an 
apoplectiform hemorrhage into the confined bony case containing the audi- 



40 DISEASES OF THE EAR IX CHILDREN. 

toiy nerves, producing a destructive pressure upon the nerve-tissues^ or it is 
a sudden displacement and tearing of the nerve-structures by concussion, 
as from a fall or a blow on the head. Doubtless this latter cause is a fre- 
quent one in children. 

This second variety is very important, from the fact that its prevention 
should be most carefully aimed at, as a cure in such cases is very difficult, 
if indeed it is at all possible. Hence all sports which include standing on 
the head, or hanging by the heels with the head down, should be prohibited, 
as tending to produce congestion and hemorrhage in the head. Further- 
more, a child in this position, or in that of so-called walking on the hands, 
is exposed to the risk of suddenly falling on its head, or striking its head 
from its disturbed co-ordination. A blow on the head, which must be con- 
gested while in such a position, is very likely to bring about destructive 
concussion of the soft tissues in the bony labyrinth. Hemorrhage and effu- 
sion into this cavity ensue, the nerve is suddenly and hopelessly impaired, 
and the child becomes absolutely and permanently deaf. Such cases I have 
observed. 

A third class of labyrinth-diseases is produced by intracranial processes, 
and also by the eifect of some general systemic disorders upon the internal 
ear. In this division we find the effects of mumps, scarlet fever, typhoid 
fever, cerebro-spinal meningitis, meningitis in general, hydrocephalus, otitis 
labyrinthica, hemorrhagic otitis, etc. 

Mumps. — Under this third division we may first consider the effect 
of mumps on the ear. That the nervous apparatus of the internal ear is 
sometimes suddenly and permanently injured by the poison of mumps, the 
process being most probably a metastatic one, has been recognized and de- 
scribed by a number of writers, from Toynbee and Hinton to the present 
time. Usually the aural symptoms consist in a simultaneous tinnitus 
aurium, vertigo, and deafness. The two first-named symptoms disappear 
sooner or later, but the deafness remains. AVhen no disturbance in equi- 
librium occurs, the metastatic process is probably limited to the cochlea, the 
semicircular canals escaping. These peculiar symptoms may not develop 
until the fifteenth day, and then only after subsidence of metastatic processes 
elsewhere. Usually there are no symptoms in the external nor middle ear 
to account for the sudden deafness following mumps. The diagnosis of the 
origin of the failure of hearing is aided by the tinnitus, nausea, vomiting, 
vertigo, and sometimes the altered gait, ensuing suddenly either during or 
after an attack of mumps. Sometimes there is pain in the ear and head, 
and in a day or two deafness, first in one ear and then in the other. It is 
supposed that in some instances the deafness and other aural symptoms are 
due to a serous exudation into the labyrinth. It is, fortunately, a rare sequel 
of mumps. No treatment has shown itself capable of either preventing or 
curing the deafness. 

Cerebeo- SPINAL Meningitis is often attended with deafness during 
the fever, and this failure in the function of the ear very frequently is 



DISEASES OF THE EAR IN CHILDREN. 41 

permanent. At the termination of the disease or during convalescence the 
patient is found to be profoundly deaf, usually in both ears. There is also 
in many cases an alteration in the walk, so that the little patient assumes a 
sailor-like gait. The lesion seems to be due to a neuritis descendens, — i.e., 
a slow encroachment of the inflammation in the interior of the cranium, 
upon the labyrinth, along the perineural vessels of the auditory nerve. 
Moos (1881) shows that in sixty-four cases of ear-disease following cerebro- 
spinal meningitis, as observed by him during eighteen years, fifty per cent, 
showed disturbances of equilibrium and hearing, fifty-nine per cent, were 
totally deaf in both ears and hence became deaf-mutes, thirty-one and a half 
per cent, were totally deaf but retained speech, while one and a half per cent, 
escaped without an aural lesion. He also observed that those left with 
hearing for high notes, but with dulness of hearing or absolute deafness 
for low notes, stood a better chance of retaining hearing for spoken words. 
If absolute deafness persists for more than three months after the cerebral 
disease, the prognosis is unfavorable, without exception. 

Treatment. — Charcot has proposed to treat the dizziness and staggering 
with large doses of quinine. His plan consists in beginning with thirty 
centigrammes of the sulphate of quinine in an adult, and gradually in- 
creasing until one gramme is taken daily. This method of administering 
quinine may be kept up for a month ; then a pause for a fortnight should 
occur ; the treatment may then be resumed for another month. Of course 
in children the dose must be proportioned to their age. Charcot's theory 
of the mode of action of the quinine in these cases is that it destroys any 
remaining function in the auditory nerve. This, however, is not accepted 
by Moos, who claims that quinine acts simply by antagonizing the inflam- 
mation. In cases where the hearing is not entirely destroyed, the constant 
electric current applied to the ear offers some hope of improvement, if made 
at once, as soon as convalescence sets in. 

Otitis Labyrinthica. — In some respects closely resembling the otitis 
interna of cerebro-spinal meningitis is an acute inflammation of the mem- 
branous labyrinth, described by Voltolini as occurring in young children. 
He reported (1872) some cases of a disease closely resembling acute menin- 
gitis, which he claims is a disease of the labyrinth peculiar to children, and 
as specific as croup. 

The symptoms may be briefly described as follows. A child five years 
old, with perfect hearing, may be attacked suddenly with vomiting, which 
lasts for several days, with intermissions, and there will be accompanying 
chill and fever. No cause can be assigned by the parents. On the first day 
of the illness the child still hears, but on the second day the hearing is en- 
tirely gone. The intellect remains clear during the entire disease, and there 
are no spasms, paralysis, nor opisthotonus. The urine and faeces are in no 
way abnormal. The child may complain of the subjective noises in its head. 
By the fourth day the appetite returns and the child begins to play. Upon 
attempting to walk, in the course of two or three weeks, the gait is very uu- 



42 DISEASES OF THE EAR IN CHILDREN. 

steady and the child has to be led about. An examination of the external 
auditory canal and membrana tympani reveals no alterations to account for 
these distressing symptoms. As death has never occurred in any of these 
cases, the precise lesion has never been determined. There are some points 
of differential diagnosis between this disease and the aural disease following 
cerebro-spinal meningitis. In the latter disease convalescence is slow and 
herpes labialis is an almost constant symptom, while it rarely appears in 
otitis labyrinthica. This latter disease is ushered in by vomiting, which is 
absent in cerebro-spinal meningitis. Then, too, the hearing is quickly and 
entirely destroyed in otitis labyrinthica, while in cerebro-spinal meningitis 
it is destroyed much less rapidly and partial audition is maintained for some 
sounds. Treatment is of no avail in otitis labyrinthica. 

Closely related to the foregoing process in the labyrinth — probably 
identical with it — is the so-called 

Primary Otitis Interna. — Toynbee, Moos, Steinbriigge, Politzer, 
and Gradenigo ^ have demonstrated changes in the labyrinth, of an osteo- 
plastic form, consecutive to a destructive pathological process in the soft 
tissues of the labyrinth. 

Toynbee found besides changes in the middle ear an osseous deposit near 
the vestibule, lying on the lamina spiralis, which entirely filled the scala 
tympani, and covered the inner surface of the membrane of the round 
window. Moos and Steinbriigge found, in a girl who had been deaf many 
years, inflammation of the labyrinth and the nerve-structures entirely want- 
ing in the first whorls of the cochleae ; also partial ossification and formation 
of connective tissue. Politzer described a case of total ossification of the 
labyrinth, found in a boy who had become deaf at the age of two and a 
half years, after an attack of fever, accompanied by great restlessness, con- 
vulsions, and a discharge from both ears, the latter lasting until the child 
was seven years old. At the age of thirteen years the child died of acute 
peritonitis, and then the post-mortem examination of the ear was made. In 
Gradenigo's case the patient was a deaf-mute girl fifteen years old. She 
died of pulmonary phthisis, and the post-mortem examination revealed com- 
plete destruction of the membranous labyrinth of both ears and the ele- 
ments of both labyrinth windows, with new formation of fibrous and osseous 
tissue, most marked in the left ear, where there was an accompanying 
chronic purulent otitis media. The new-formed bone-tissue was developed 
partly from the endosteum of the labyrinth cavity, and partly by direct 
metamorphosis of new-formed fibrous tissue. There were no traces of semi- 
circular canals : the vestibule was narrowed. In the cochlea the new osseous 
tissue diminished in quantity as the cupola Avas approached. 

Gradenigo^ further shows that otitis interna may be due primarily 
to hereditary syphilis, and secondarily to cerebro-spinal meningitis, and 

1 Archiv fiir Ohrenheilkunde, 1887, Bd. xxv. p. 46. 

2 Ibid., 1887, Bd. xxv. p. 237. 



DISEASES OF THE EAR IN CHILDREN. 43 

sometimes, though rarely, to otitis media suppurativa (panotitis) in chil- 
dren. 

Hemorrhagic Inflammation of the Labyrinth in Children. — 
It has been demonstrated by post-mortem examination ^ that hemorrhages 
and hemorrhagic inflammation occur in the labyrinth of children. This 
may be best understood from the following history of a case. 

A boy three and a half years old was affected with symptoms of a mild 
cerebro-sjDinal meningitis. On the teuth day he had begun to manifest 
symptoms of improvement, but the day after he became suddenly deaf. 
For three days preceding this event he had complained of intense tinnitus 
anrium. Symptoms of meningitis, with strabismus, now returned. Three 
weeks after the relapse the patient was emaciated, vomiting, and insensible. 
Eight weeks after the beginning of the illness the patient died, apparently 
in consequence of tubercular meningitis. The post-mortem examination 
revealed signs of internal hydrocephalus and a tendinous thickening of the 
pia mater at the base of the brain. The dura mater covering the petrous 
bone was reddish, blue, and green, especially in the region of the semicir- 
cular canals. The osseous semicircular canals were filled with fluid blood 
and dark-red coagula. The vestibules also were filled with blood ; the 
cochleae contained less. Pus was found in the canals and in the broken- 
down membranous parts of the labyrinth generally. The vessels of the 
lamina spiralis were greatly congested, and Corti's membranes in both 
cochleae very much thickened. There were no evidences of tubercles in 
the labyrinth. 

Careful examination seemed to show that the disease had reached the 
labyrinth by means of a reduplication of the dura mater, very rich in blood- 
vessels, which extended into the hiatus subarcuatus, the space beneath the 
superior semicircular canal, which exists in children, not yet having been 
filled up with bony tissue. There was also an osteo-myelitic condition of 
the spongy tissue of the bone about the labyrinth, which had induced the 
hemorrhagic inflammation of the membranous labyrinth. It seems proba- 
ble that this is the way of transmission of inflammation from the meninges 
to the labyrinth in many cases, and it may explain instances of sudden 
deafness iu children. 

Disease of the Labyrinth in Typhoid Fever. — In typhoid 
fever the entire labyrinth is often affected upon one or both sides. The 
parts more usually affected are the utriculus, the sacculus, the ampullae, and 
the lamina spiralis membranacea. The semicircular canals are not so likely 
to be affected. Histologically the affection consists in a small cell-infiltra- 
tion, — i.e., an infiltration of small lymphoid cells (Moos). 

The Labyrinth in Scarlet Fever, etc. — Ambilateral inflamma- 
tion of the labyrinth has been found in cases of scarlet fever complicated 
with diphtheria, suppuration of the parotid gland, otitis media purulenta, 

1 Lucae, 1882. 



44 DISEASES OF THE EAR IN CHILDREN. 

and periostitis of the left squama, iu which death occurred from secoudaiy 
meningitis (Moos). The condition of the labyrinth in such cases is held to 
be an explanation of all cases of great hardness of hearing after scarlet 
fever, in which an analysis of the other clinical symptoms unconditionally 
excludes the supposition that a concomitant cerebral affection has caused 
the destruction of hearing. 

Purulent inflammation of the labyrinth has been found in children who 
have died of variola. 

Effects of Quinine and Salicylic Acid upon the Internal 
Ear. — Large doses of quinine produce congestion of the membrana tym- 
pani, the middle ear, and the labyrinth. Fifteen grains given at once to an 
adult will produce all the well-known symptoms of quinine-poisoning, and 
may be followed by permanent alteration in the function of hearing. Of 
course smaller doses will produce similar bad effects in children. It has been 
demonstrated by the experiments of Kirchner^ that hypereemia and hemor- 
rhages in all parts of the labyrinth may ensue from large doses of quinine 
and salicylic acid. Thus, in a cat to which large doses of quinine had been 
given, a copious extravasation of white and red blood-corpuscles extended 
over large areas of the cochlea. In a preparation taken from a rabbit an 
extravasation could be seen extending from the semicircular canals to ves- 
sels of the surrounding osseous tissue. In a woman who had taken for a 
long time large doses of salicylic acid Kirchner found, iu addition to symp- 
toms of labyrinthine congestion, an exudation into the middle ear, w^hich 
necessitated paracentesis of the membrana tympani. In cases of acute 
quinine-deafness it may be assumed that paralysis of the vessels and exuda- 
tions ensue in various parts of the auditory apparatus. 

Salicylate of sodium and salicylic acid do not seem to affect the ear as 
quickly nor as extensively as quinine. However, doses of fifteen grains 
every hour for five hours may induce permanent changes in hearing 
(Schw^abach). To overcome the vessel-dilating effect of these two drugs it 
is recommended by Schilling that the vessel-contracting drug ergot be given 
shortly after these two drugs are administered. In eighty-seven cases in 
which salicylate of sodium was combined with ergot seventy-six per cent, 
of the cases were entirely free from effects of the drug upon the hearing. 
In nine cases in which ergot was combined with quinine no aural symptoms 
were observed. The antirheumatic and antifebrile effects of these drugs 
are not diminished by their combination with a controlling drug. In this 
connection it will be well to recall the suggestion of Tinkler and Prior ^ 
that amorphous borate of quinine is an efficient antipyretic and antiperiodic 
reniedy, and possesses, besides, the great advantage of not inducing tinnitus 
auriura to the same extent as the muriate of quinine. This was demon- 
strated by experiments upon themselves by the above-named observers. 



1 Archiv fiir Ohrenlieilkunde, Bd. xviii. p. 305; ibid., Bd. xx. p. 209. 

2 Deutsche Med. Wochenschr., 1884, No. 6. 



DISEASES OP THE EAR IN CHILDREN. 45 

Therefore, when the clinician resorts to large doses of quinine at a time, 
a controlling drug should be employed, in order both to give the patient 
comfort and to save his internal and middle ears from permanent injury. 

Malformations of the Internal Ear. — For a detailed account 
of malformations of the ear and the literature of this subject the reader 
may consult Von Troeltsch's "Diseases of the Ear in Children," and 
Schwartze's " Pathological Anatomy of the Ear," both of which are trans- 
lated into English by J. Orne Green, M.D., of Boston. It is sufficient to 
note here a condensation of facts as presented in the above-named works. 

The entire labyrinth may be wanting, or it may be but partially de- 
veloped ; in the latter case some of its parts, most commonly the semi- 
circular canals, are absent, or they exist only in a rudimentary form. 
Variations in the form and size of certain parts are very common, but these 
variations are said to be symmetrical. The possibility of a malformation 
or arrest of development being confined to the inner ear is explained by 
the development of the ear, the labyrinth being formed from its own so- 
called labyrinth-vesicle in the region of the cerebellum, while the middle 
ear and the auditory canal are formed from the first branchial fissure, and 
the ossicles from the two first branchial arches. The ossification of the 
labyrinth is said to be finished sooner than that of the external portions of 
the petrous bone. In some very rare cases congenital absence of the audi- 
tory nerve has been observed in connection with defects in the labyrinth. 

DEAE-DUMBNESS : THE NEKYOUS LESION. 

The lesion in congenital deaf-dumbness may be an early periostitis of 
the petrous bones. This is shown by the sclerosis in the substance of the 
bones, the ankylosis of the ossicles, the partial hyperostotic condition of 
the bony walls of the tympanic cavity, and the closure of the fenestra 
rotunda. A colloid substance may be found in the labyrinth in such cases. 
In some instances the semicircular canals, the ampullae, and the cochlea are 
wanting. The auditory nerves may be atrophic and contain concretions of 
phosphate of lime. In such cases the auditory vesicle alone is arrested in 
development. In other cases an examination of the labyrinth on both sides 
reveals a large quantity of otoliths and numerous colloid bodies in the am- 
pullae, in the sacculi, and on the membranous lamina spiralis. The aboli- 
tion of hearing is often directly due to colloid degeneration in the labyrinth. 

In some cases of congenital cleaf-muteness some of the inner convo- 
lutions of the posterior lobes of the cerebrum are considerably atrophied, 
discolored yellow, and oedematous, as shown by post-mortem examinations 
(Moos, Steinbriigge, Luys, and others). 

Aural Hygiene in Deaf-Mutes. — Deaf-dumbness may be either 
congenital or acquired ; in some instances the two forms may be united. 
The congenital form of deaf-dumbness was once considered the commoner 
occurrence. But later investigations have shown tliat this is by no means 
the truth. Thus, in the Pennsylvania Institution for the Deaf and Dumb 



46 DISEASES or THE EAR IN CHILDREN. 

in Philadelphia, within three years one hundred and thirty-seven children 
were admitted who had lost their hearing from fevers and other known 
causes, and had thus become deaf. These constituted two-thirds of the 
entire number of admissions, thus, demonstrating that, in this institution 
at least, congenital deaf-muteness is considerably less frequent than the 
acquired form. 

Every physician may be called upon to decide whether a child is deaf 
and dumb, and, if it be, to suggest, if not a cure for the deafness, at least 
a plan for the proper care and education of the little patient. 

Mute children are very apt to suffer from earache and sometimes from 
chronic discharges from their ears. These symptoms should be most care- 
fully combated according to plans already given, in order to make the child 
more comfortable and to retain or improve any remaining hearing. 

In very young children it cannot be readily determined, except by an 
expert, whether total deafness exists or not. But whether or not the child 
is totally deaf, — and very few mutes are entirely deaf, — it may be too deaf 
to learn to talk by hearing others speak. An opinion on this point is rarely 
sought for until, the child having reached the age when most children begin 
to use words intelligently, it arouses suspicion as to its defect by showing no 
evidence of learning to talk. The mere utterance of the words " mamma" 
and "papa" is no proof that the child hears, as these elementary sounds may 
be made quite involuntarily by very young children. 

The child having reached the age of two years and given evidence of 
being a deaf-mute, it remains for us to consider what can be done for its 
education. 

In all civilized communities there are provisions for the proper cor- 
poreal, moral, and intellectual training of the deaf and dumb. Deaf-mutes 
naturally communicate with one another by means of a sign-language, 
M^hich in most respects is common to mutes of all nations. This method, 
scientifically elaborated, is termed dactylology, or finger-talking. Until 
within a few years it has been the only chief method of instructing deaf- 
mutes in England and the United States. 

The system of educating mutes by teaching them to understand and to 
use articulate speech by observing and imitating the speech of others, in 
which method the pupils are not taught to use the sign-language at the same 
time, has been employed for a long time in most of the countries of Conti- 
nental Europe. There are records which prove that in England at the be- 
ginning of the eighth century mutes were taught to understand the motions 
of the lips, and again in the seventeenth century Bulwer and Wallis, of the 
University of Oxford, induced some teachers to devote themselves to the 
instruction of deaf-mutes by means of lip-reading. In order to become edu- 
cated by this manner the child must possess ordinary intelligence and normal 
vocal organs, and must begin its studies in this direction at not later than 
seven years of age. The average length of time demanded in the study of 
this method, before the pupil can understand and communicate with any one 



DISEASES OF THE EAR IN CHILDREN. 47 

it may meet, is about eight years. But great attainments are thus made. 
English children thus skilled have learned to speak French and German. 
In Vienna I have conversed in German with mutes who understood me 
and replied in their own tongue. Their proficiency was such that they 
perceived I was a foreigner by my speech. 

The writer feels very sure that many mutes retain more hearing than is 
supposed. This function remains, as it were, latent, because it is difficult 
to use it and hence develop it by ordinary vocal sounds of conversation. 
If, however, a speaking-tube is used, even in those who have long been 
mutes, more or less hearing is discovered. Of course what is said to them 
is often heard better than is supposed from their imperfect reproduction or 
translation of what is said. This is very much as it is when a foreign and 
unknown language is spoken to any one with good hearing. He hears what 
is said, but, being unaccustomed to utter the sounds of the foreign tongue, 
he cannot repeat them. So it is with the mute who hears a little : he cannot 
reproduce what he hears, or he does it imperfectly. If, however, a little 
patient labor be bestowed in speaking to him every day through a good ear- 
trumpet, his latent hearing can be developed, and it will become an immense 
aid in teaching lip-reading and articulation. For this purpose no better 
instrument exists than Maloney's otophone, already mentioned (p. 36). 

HYGIENE OF DEAF CHILDREN. 

1. There is a large number of children, all of whom have learned to 
talk, but who are too deaf to go to school or to learn anywhere by hearing 
the ordinary speech of other people. Many of these drift into institutions 
for the deaf and dumb. Those who enter these institutions soon lose their 
ability to speak or become very imperfect in it, from want of hearing others 
and from lack of practice. The inducement to talk soon goes when hearing 
what others say is no longer possible or is possible only with great difficulty. 

2. There is also a large number of speaking children who hear very 
poorly, and will become semi-mutes or very imperfect users of speech unless 
carefully watched, both as to what they hear and how they speak. Sucih 
deaf children find it very difficult to keep up in their studies with children 
who hear well. They should, however, continue to go to school with hear- 
ing children, as it perfects their speech and their hearing if these are exer- 
cised as they must be in schools of hearing children. If they continue in 
such schools, however, they must be favored by seats near the teacher. The 
latter must be fully apprised of the amount of deficiency of hearing in any 
deaf pupils, and fully aroused to the importance of making some simple 
efforts at favoring hearing on the part of the deaf. It is a great advantage 
for the deaf child who hears some and knows how to speak to struggle on 
with children who hear and talk well, rather than to be consigned to a 
school for deaf-mutes, where it may lose all ability to hear, and will 
certainly lose the ability to talk. 

In regard to the first class it may be said that at present there is no 



48 DISEASES OF THE EAR IN CHILDREN. 

provision for their proper instruction. The poor of this class are forced to 
enter institutions for deaf-mutes, where they learn much and are also taught 
some trades. The rich of this class are now taught lip-reading and articu- 
lation, either by private tutors or in private schools. All of this class, both 
poor and rich, should be taught in a special way, or at least their instruc- 
tion should be largely conducted, by making them hear through speaking- 
trumpets. This method should be begun early, as soon as the child gets 
too deaf to hear in the natural way. By doing so, the hearing may be not 
only kept from going entirely, but even improved. 

In order that this plan of instructing the deaf child and improving his 
hearing and his speech may be appreciated, let me recall the mechanism of 
hearing and the anatomical basis of it. 

Sound-waves falling on the membrana tympani force it inward and at 
the same time carry inward the malleus. The hammer bonelet, articulating 
with the incus, carries it inward also, and the latter forces the stapes into 
the oval window. Thus, then, we have sketched the mechanism of an in- 
ward excursion of the three auditory bonelets in the middle ear, articulated 
to one another in the so-called chain of ossicles. By such an excursion the 
labyrinth fluid and the auditory nerve in the labyrinth are impressed. It 
is now seen that hearing depends on the movement of joints, like those 
between bones in any other part of the body. If these grow stiff, as they 
do in catarrh of the middle ear, their mobility is impaired and hearing 
grows dull. If this impeded motion continues long, the nerve of hearing 
falls into disuse and fatty degeneration ensues. Just as in the case of anky- 
losis of any other joints, passive motion will overcome the impaired func- 
tion. Instead of using our hands and arms to promote this passive motion, 
as in other large joints, in the ear the joints are movable only by sound- 
waves falling on the drum-membrane, upon the membrane of the round 
window, or upon the bonelets themselves if the membrana tympani be 
destroyed or perforated. In the deaf ear, the ordinary vocal sounds do not 
produce sufficient impression to overcome the ankylosis in the ossicles, and 
the patient is said to be deaf. If, however, ordinary sounds or louder ones 
be concentrated and conducted to the drum in more than ordinary quantity 
and intensity, the ankylosis is overcome temporarily and the child hears. 
If this is repeated systematically, the ankylosis, like such an imjjediment 
elsewhere, is overcome, and the hearing is made permanently better than it 
would be if allowed to remain unexercised. 

I am fully convinced of such good result of a rational use of artificial 
means to convey sound to the deaf. It must be done patiently and sys- 
tematically, but it has been done by placing the mouth close to the ear of 
the very deaf, by parents for their children, and by wives for their husbands. 
What may not be done for a number of deaf children brought together and 
taught by conducting the voice of the teacher to their ears by good ear- 
trumpets ! They will be rescued from great deafness, and be improved in 
hearing and saved from being mutes. 



DISEASES OF THE EAR IN CHILDREN". 49 

In regard to the second class (p. 47) it may be said that, in order to 
make allowance for their defective hearing, a careful examination should be 
made in each case, in order to determine the extent of deafness.^ This is 
done by finding out at what distance the voice of the teacher can be heard, 
in ordinary conversational tones. Tests should also be made to discover 
the distance at which consonant tones are heard by the deaf child. The 
child to be tested should be placed in front of the teacher, who should be in 
his accustomed place in the school-room. Then, with the ears alternately 
stopped, let the child be gradually brought to a point in the room w^here it 
hears and repeats the tests employed. Here the child should have its per- 
manent seat. The tests to be employed are isolated words, — not sentences, 
because the latter can often be guessed by the context. 

This test might be made by an expert, who can also examine the ears 
and discover whether any remediable disease be still present in the organs 
of hearing. 

Dr. Samuel Sexton, of New^ York, has suggested that teachers often 
have defective hearing. This should be guarded against as far as possible 
by examining orally candidates for admission to the ranks of teachers in the 
public schools. 

^ Dr. C. J. Blake, of Boston, found that in eight thousand seven hundred and fifteen 
cases of ear-disease two thousand one hundred and seventy-five, or twenty-five per cent., 
were children under fourteen years of age, all of them pupils in the public schools. 



Vol. IY.— 4 



PART II. 

THE EYE. 



AFFECTIONS OF THE EYELIDS, LACHRYMAL 
APPARATUS, CONJUNCTIVA, AND CORNEA. 

By G. E. de SCHWEINITZ, M.D. 



AFFEOTIOI^S OF THE EYELIDS. 

Disorders of the eyelids naturally divide themselves into affections 
of the eyelid border and its tissues, new growths, affections of the muscles, 
affections of the cilia, vices of conformation, and congenital faults. 

BLEPHAEITIS. 

Synonymes. — Many names are current for the various types of the 
disorder blepharitis. The late Prof. Frederic Horner ^ describes this affec- 
tion under two headings: 1. Seborrhoea of the ciliary border. Blepharitis 
simplex, Blepharo-adenitis, Blepharitis ciliaris. 2. Eczema of the ciliary 
border (Blepharitis ciliaris, Blepharitis ulcerosa, Psorophthalmia, Lippi- 
tudo ulcerosa, Tinea tarsi, etc.). In a work by De Saint-Germain and E. 
Valude ^ the following classification is adopted : Scrofulous blepharitis 
and Eczematous blepharitis. The former variety is discussed under the 
two headings Hypertrophic scrofulous blepharitis and Ulcerative scrofulous 
blepharitis. 

Definition. — Blepharitis is a general term which describes the various 
types of acute and chronic inflammation of the border of the lid. 

Etiology. — Blepharitis is quite distinctively a disease of childhood, and 
often begins long before the age of puberty. It consists either in hyper- 
semia, a hypersecretion of the sebaceous glands, or an eczema of the lid- 

1 Handbuch der Kinderkrankheiten, C. Gerhardt, Tubingen, 1882. 
^ Traite pratique des Maladies des Yeux chez les Enfants, Paris, 1887. 
50 



AFFECTIOXS OF THE EYELIDS. 51 

margin. Children with pallid complexion and lig4it hair and of strnmous 
constitution are particularly liable. It often follows an attack of measles. 
Lack of cleanliness and imperfect hygienic surroundings are exciting causes, 
while insufficient length of the skin of the upper lid, in some instances, 
according to Fuchs,^ is a predisposing condition. Since Roosa's^ investi- 
gations, refraction-error, especially hypermetropia, is known to originate the 
disorder in many instances, though certain writers, like Swanzy and Berry, 
while ready to believe that ametropia may keep up the affection if present, 
are disinclined to look upon this as a basal cause. Just as blepharitis is an 
independent disorder and may give rise to secondary changes in the other 
parts of the eye, so it may also originate from any long-standing hyper- 
aemia of the conjunctiva, affections of the lachrymal apparatus, and coexist- 
ing nasal disease. Exactly what role bacteria play in the production of this 
complaint cannot be definitely stated. In the hands of Gallenga^ cultures 
made from abscesses in a case of ciliary blepharitis gave origin to colonies 
of staphylococcus aureus and albus ; and Widmark * found in the little ab- 
scesses at the roots of the lashes in ca-ses of blepharo-adenitis staphylococcus 
pyogenes albus and aureus. Hirschberg,^ under the name vaccine blejjharitis, 
reports the appearance of vaccine vesicles on the middle free border of the 
lids of a man who played with children recently vaccinated ; an inquiry 
instituted among nearly a thousand cases of vaccination done in this city 
discovered no similar instance.^ 

Symptoms. — The disease may vary from a simple redness, the hyper- 
semia of the lid-border of some writers, to severe ulceration. In the milder 
types the ciliary margins are slightly thickened, red, and sore, while small 
scales and occasionally pustules appear, and if these be removed a yellow- 
ish sebaceous matter is seen beneath. The nutrition of the lashes is not 
seriously interfered with in this variety, which is often spoken of as mar- 
ginal eczema or blepharitis simplex. To that form in which the eyelids 
under the slightest provocation grow red, the eyes weep and feel hot, the lids 
swell, and the conjunctiva is injected, while crusts are but scantily present, 
the term vaso-moior blepharitis has been applied. In another common and 
stubborn variety, which has its origin in the follicles of the eyelashes, the 
border of the lid is thickened, dusky, and congested ; the edges are smeared 
with tenacious secretion ; the lashes are gathered into little tufts by the col- 

1 Wien. Klin. "Wochenschr., 1888, Nos. 38 and 39. 

2 Transactions of the American Ophthalmological Society, 1876. 
^ Annales d'Oculistique, xcviii. 51. 

* Nord. Ophth. Tidsskrift, Nos. 1 and 2, 1888 ; Archives of Ophthahiiology, December, 
1888. 

' Centralblatt f. prakt. Augenheilkunde, 1885, ix. See also another case of vaccine 
blepharitis, Hirschberg, Archives of Ophthalmology, xv. 

^ Under the title "Vaccinal Ophthalmia," S. T. Knaggs (Transactions of the Oph- 
thalmological Society of the United Kingdom, i. 16) has described violent ophthalmia 
and later hypopyon-keratitis in a mother whose recently-vaccinated child inoculated 
her eye. 



52 AFFECTIONS OF THE EYELIDS, 

lection of matter at their bases ; scabs covering small ulcers and pustules 
ai^pear, while the cilia are loosened and their removal is followed by bleed- 
ing ; the lashes become misplaced, stunted, and deficient ; cicatricial changes 
follow the subsidence of the swelling and cause slight eversion of the lids, 
as a result of which their borders are deprived of cilia, are raw and tender, 
and the appearance thus produced has received the name lippitudo. In the 
severest types, all four lid-borders may be attacked simultaneously, the lids 
are oedematous and highly congested, the margins beset with thick yelloAv 
crusts through which groups of lashes, glued together, push their way. 
Removal of these reveals beneath bleeding and ulcerated pits which extend 
inward as far as the tarsus ; in short, the entire lid-border is lined with 
small crater-like abscesses. This blepharitis ulcerosa, as well as the less 
aggravated forms, not infrequently is associated with eczema of the auricle 
and nares, nasal catarrh, and diseases of the lachrymal apparatus, each stand- 
ing in relation to the other either as cause or as effect, the whole forming 
what not inaptly has been described as a vicious circle. 

Prog-nosis. — The earlier the cases come under proper treatment, the 
more favorable the prognosis, and hence it is particularly in childhood that 
radical cures may be effected. Long-standing cases that have resulted in 
rounded, everted lid-margins, deprived of lashes, and with closed and mis- 
placed lachrymal puncta, are rebellious to all forms of medication. 

Treatment. — The local measures in the milder forms consist in the use 
of a lotion of boric acid and the application to the edges of the lids of a salve 
of the yellow oxide of mercury (gr. i-3i). In that variety, however, de- 
scribed under the term vaso-motor blepharitis the use of salves is contra- 
indicated, and the best results, according to Koenigstein,^ are reached by 
douching the closed lids with water at a temperature of 60° F. from a 
vessel raised a short distance above the head of the patient, the fluid being 
conducted through a small apparatus in the form of the rose ordinarily seen 
upon watering-cans. Whenever scales are present these must be taken 
away, either by means of warm alkaline solutions, of which bicarbonate of 
sodium (gr. viii.-f .^i) and biborate of sodium (gr. iv-f^i) are the best, with 
a five-per-cent. solution of chloral, as recommended by Gradle,^ or with 
forceps. Gradle advocates a three-per-cent. mixture of milk of sulphur 
with vaseline and the addition of three per cent, of resorcin. During 
severe inflammatory attacks, and even in old cases, results surprisingly 
beneficial follow the removal of all the lashes with a cilia-forceps. In 
ulcerated blepharitis, after the removal of the crusts and loose cilia the 
ulcers should be painted with a solution of nitrate of silver, and may even 
be cautiously touched with the point of a mitigated stick. Michel advises 
that unguentum diachylon Hebrse with oil of sweet almonds be spread upon 
pieces of lint so shaped as to cover the lids, and containing apertures 

^ Die Behandlung der haufigsten und wichtigsten Augenkrankheiten, Wien, 1889. 
2 Medical News, February 8, 1890. 



LACHEYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 53 

through which the cilia, if present, may pass, and allowed to remain over- 
night. Kroll recommends that Pagenstecher's ointment (hydrarg. oxid. 
flav., gr. i ; cosmoline, 3i) be rubbed in until the scales are removed, and 
then the lid-border pencilled with nitrate of silver, one to fifty. In the 
hands of Schweigger iodine on the edges of the lids has proved beneficial. 
In all cases the lachrymal passages and the nasal cavity should be exam- 
ined, and, if epiphora exists, the canalicalus slit. Any error of refraction, 
after the eyes have been carefully atropinized, is to be corrected with suit- 
able glasses. 

The best constitutional measures are quinine, iron, especially in the form 
of the iodide, cod-liver oil and malt, together with appropriate nourishing 
diet. Fresh air and a daily salt bath are highly desirable. 

PHTHIKIASIS PALPEBKAKUM. 

Synonymes. — Blepharitis pediculosa, Phthiriasis ciliarium. 

The pediculus pubis (crab-louse), besides its seat of predilection, occa- 
sionally infests the eyebrows, and very rarely the eyelashes. The rarity of 
the affection is attested by the fact that Hirschberg ^ among forty thousand 
cases of eye-disease met with only three instances. Despagnet^ during 
twelve years of Galezowski's service found but two recorded examples ; and 
among more than^ten thousand patients in the service of Prof. AVilliam F. 
Norris at the University Hospital only two instances have been observed.^ 

Symptoms. — On superficial examination the lashes appear to be covered 
with small, dark spots like grains of powder, which upon closer inspection 
resolve themselves into the lice clinging closely to the lids, while the eggs, 
darker in color, are fastened with great regularity along the roots of the 
cilia; in many instances the parasites are buried head-foremost in the 
hair-follicles. Their presence causes severe irritation, and the case may be 
mistaken for an ordinary marginal blepharitis. A magnifying lens will at 
once clear up the diagnosis. 

Treatment. — Cleanliness, together with balsam of Peru, or mercurial 
ointment, or a cautious pencilling with a solution of corrosive sublimate, 
will remove the intruders. 

HOKDEOLUM. 

Synonymes. — Stye, Hordeolosis. 

Hordeolum is an inflammation of the tissues of the edge of the eyelid 
or of one of its sebaceous glands. Exposure to artificial light, to dust, and 
cold winds are the most usual exciting causes. Eyes that are subject to 
styes are often ametropic, hypermetropia being the most usually observed 
refraction-error. Styes tend to appear in crops, and occasionally produce 
great -swelling and oedema of the lid until an appearance like the commence- 

1 Berlin. Klin. "Wochenschrift, 1882, xix. 

^ Kecueil d'Ophtalmologie, November, 1887, p. 674. 

* University Medical Magazine, March, 1889. 



54 AFFECTIOXS OF THE EYELIDS, 

ment of purulent ophthalmia is produced. By observing the circumscribed 
character of the swelling and the absence of purulent secretion from the 
conjunctiva, an error may be avoided. In like manner a stye may simulate 
an acute inflammation of the lachrymal sac. Usually the small inflamed 
swelling on the edge of the lid increases in size for a few days and then 
resolution or suppuration occurs. 

Treatment. — Warm fomentations, especially in the form of hot-water 
compresses, give speedy relief. If suppuration occurs, the contents should 
be evacuated with a knife. Saturated solutions of boric acid, according to 
Abadie, cause a rapid cure. A stye occasionally may be aborted by paint- 
ing its surface with collodion, and the vigorous application of a salve of the 
red or yellow oxide of mercury has produced the same result. The refrac- 
tion of the eye should be examined in all cases, and if this is anomalous, 
as it usually is, the proper correcting glass is to be ordered. Associated 
conjunctivitis must be treated with a mild astringent or antiseptic wash, 
while internally iron and quinine, and, if the styes come in groups, the 
sulphide of calcium, as recommended by Webster, may be exhibited. Con- 
stipation must be relieved by suitable remedies. 

CHALAZION. 

Synonymes. — Meibomian cyst. Tarsal tumor. 

A chalazion is a small tumor or retention-cyst due to a chronic inflam- 
mation of a Meibomian gland together with the surrounding tissue. 

The etiology of these little growths is obscure. They may be asso- 
ciated with inflammation of the border of the lid, which aids in closing the 
duct of the Meibomian gland. Poncet and Boucheron^ have described 
microbes in connection with chalazia, though Vassaux ^ and other observers 
have failed to find them except in such as already had undergone suppura- 
tion. They are more common in adolescence than in very young children 
or in old age, but are not infrequently found in infants. 

Patholog-ical Anatomy. — According to Felix Lagrange,^ the chalazion 
has three periods of development, — retention of the products of the Mei- 
bomian gland ; consecutive adenitis and periadenitis, with destruction of the 
cartilage ; and passage of the tumor to the conjunctiva (internal chalazion) 
or to the skin (external chalazion). Lagrange believes that microbes play 
only a secondary part in the production of the affection. If examined, the 
cysts contain pus, puriform fluid, and cholesterine crystals, together with 
surrounding granulation-tissue. There is no true cyst-wall. 

Symptoms. — The tumor grows slowly and forms a firm swelling, 
tightly attached by its under surface to the tarsus ; over it the skin is 
usually freely movable ; occasionally adhesions between it and the integu- 



1 Bull, et Mem. de la Soc. rran9. d'Opht., Paris, 1886, iv, 88-91. 

2 Ibid. 

^ Archives d'Ophtalmologie, May-June, 1889. 



LACHRYMAL APPARATUS, COXJUXCTIVA, AND CORNEA. 55 

ment occur. On the conjimctival surface of the lid a bluish patch marks 
its position. Suppuration may take place in the cyst, and, like styes, these 
tumors tend to come in crops. 

Diagnosis. — A chalazion is to be distinguished from an ordinary 
sebaceous tumor by the firmness of its attachment to the tarsus, and, if 
it suppurates, from a stye by the more circumscribed character of the 
inflammation. It may be mistaken for a round-celled sarcoma of the 
lid, an interesting instance of vv^hich has been recorded by Randall,^ where 
the microscope was necessary to settle the diagnosis. 

Treatment. — If the growth points towards the conjunctival surface, it 
is to be removed from this side ; if not, the incision should be made over 
it in the skin parallel with the muscle-fibres, and the mass carefiilly dis- 
sected out, care being taken not to perforate the conjunctiva. Operation is 
facilitated by having the lid steadied with a clamp (Desmarres, Snellen, or 
Knapp). The assiduous use of hot water and the application of yellow 
oxide of mercury salve are often resorted to with the hope of producing 
resolution. Removal by the knife or scoop is the only practical measure, 
though the local means above mentioned may be useful to aid in the dis- 
sipation of any inflammatory thickening which remains after the operation. 

PosT-VARiOLOUS Ulcers OF THE Eyelids. — A favorite spot for the 
pustule of small-pox is the border of the lid. Not only may this result in 
the ordinary scar, the sequel of cicatricial contraction, with loss or faulty 
position of the cilia, but occasionally a long time after the eruption has dis- 
appeared ulcers remain which stubbornly resist treatment. Horner (loc. 
clt.) has seen such variolous ulcers ten years after the original disorder. 

Furuncles are not infrequently seen in children, especially in the 
outer half of the eyebrow as well as within the tissue of the lid. They 
occur as a red swelling, move with the skin, are unattached to the bone 
or periosteum, and are soon capped with a yellow point of suppuration. 
They should be treated by warm fomentations or flaxseed poultices, and 
early incision shortens their existence. 

CEdema of the Eyelids. — This is an affection characterized by an 
cedematous condition of the cellular tissue of the eyelids, which may be 
fugitive or persistent, and is not infrequently recurrent. R. W. Doyne^ 
reports the case of a girl aged fifteen, the subject of migraine and myopia, 
with recurring swelling of the upper eyelids, the oedema sometimes standing 
out on a level with her brows. Mr. Gunn^ believes these cases are all 
of the nature of urticaria. They may appear in connection with the estab- 
lishment of menstruation, but sometimes occur in otherwise healthy chil- 
dren, spontaneously and without cause, and in boys, as reported by W. J. 



^ Transactions of the American Ophthalmol ogical Society, 1887. 

2 Transactions of the Ophthalmological Society of the United Kingdom', viii. 41. 

3 Ibid. 



56 AFFECTIOXS OF THE EYELIDS, 

Collins^ and others, CEdema, of the eyelids, when present as part of a 
general condition — renal or cardiac — or from injury, should be distinguished 
from these cases of transient oedema by observing the history of the 
case. If the case calls for treatment, this may consist in bathing the parts 
with dilute lead-water and laudanum and the internal administration of 
Basham's mixture. QMema of the eyelids when associated with general 
disease necessarily receives the same treatment as that directed to the relief 
of the constitutional disorder. 

Erysipelas may attack the eyelids, and in this situation does not 
diflFer materially from this disease in other portions of the body. It is 
much less seldom peculiar to this region than it is as part of an attack of 
general facial erysipelas. It is one of the causes of orbital cellulitis. 

Phlegmonous Inflammation (Pseudo-Erysipelas) and the formation 
of lid-abscesses of a mild type is not an unusual disorder during the early 
months of childhood : it is confined almost exclusively to the upper lid, 
which becomes red and swollen, and in a few days palpation reveals the 
presence of pus. In other cases a much more severe type is manifest. It 
begins wdth the formation of a pustule, quickly followed by great swelling 
and accompanied by high fever. The skin and subcutaneous tissue may 
become sphacelous after the formation of one or more pustules of dark 
color {cedhne malin of French Araters). Hilbert^ has described cases of 
a peculiar gangrene of the lid in children who were well nourished, rosy, 
and never before ill, — cases which bore no resemblance to noma, malignant 
pustule, oedema malignum, phlegmon, or multiple cachectic lid-abscesses. 

Etiology. — If secondary lid-abscesses, and especially acute conjunctival 
processes, are excluded, the origin of these cases may be looked for either 
in a traumatism or as the result of an infectious process^ although the 
causes are by no means always evident. Lid-abscess has been reported as 
a sequel of influenza by Landolt. I have observed similar instances.^ In 
many cases contact wdth infectious disorders in animals gives rise to the 
disease, — an explanation not so readily applied to children as to adults. 
Michel, however, quotes a case in which a child was suddenly seized with 
this affection of the lids after coming in contact with straw that had been 
used for horses suffering with glanders. 

Treatment. — This naturally directs itself to lessening the constitutional 
disturbance and to the local condition. The latter should be treated with 
warm fomentations, early incision, and antiseptic dressing. Subcutaneous 
injections of carbolic acid have proved useful in the hands of Horner, 
and Delens has reported success with similar injections of iodine. If de- 
formity of the lid result from the disease, this must be restored by a plastic 
operation. 



1 Transactions of the Ophthalmological Society of the United Kingdom, viii. 4L 
^ Vierteljahrschrift fiir Dermatologie, Wien, 1884, xi. 117-119. 
3 Medical and Surgical Reporter, March 15, 1890. 



LACHRYMAL APPARATUS, COXJUXCTIVA, AXD CORXEA. 57 

SYPHILIS OF THE EYELIDS. 

Syphilitic affections of the eyelids may be divided into ulcerations and 
eruptions, and may exist as the primary sore or in the form of secondary 
or hereditary manifestations. A chancre upon the lids may have its seat on 
any portion, but the delicate skin of the ciliary border is the favorite region. 
Among one hundred and eighteen cases of all ages collected by Alexander,^ 
the skin of the eyelid was affected sixty-five times, the tarsus sixteen 
times, and the conjunctiva thirty-seven times. Associated with the local 
lesion in the eyelids, the lymph-glands in front of the ear and at the angle 
of the jaw are much enlarged. Contagion usually occurs from an infected 
attendant, not infrequently the mother. J. V. Solomon ^ has recorded an 
instance of an indurated syphilitic ulcer at the inner end of the eyelid edge, 
which occurred in an infant eight months old, who had been inoculated by 
an aunt at that time suffering with specific ulceration of the tonsils. A 
primary syphilitic sore on the upper eyelid of a boy aged six is described 
by Mackay.^ A papular eruption appeared six weeks after the initial 
lesion ; the origin of contagion was probably from a diseased mother. The 
frequency with which chancres in the eyelids of children have occurred (in 
ninety-four cases collected by De Beck,* ten were found among infants or 
young children) led M. Baudry,^ of Lille, to investigate their etiology. 
In one case, a female child twenty-two months old, an indurated chancre 
appeared on the free edge of the lower eyelid. Investigation showed that 
the infant was nursed by a woman who wiped its eyelids with her saliva, 
the woman being at the time the subject of syphilitic ulceration of the 
mouth. Inquiry elicited the fact that women among the peasant folk were 
accustomed to cleanse the eyelids of children in this manner when they 
were glued together with discharge from the conjunctival cul-de-sac. 

Infants the subjects of hereditary syphilis are sometimes affected with 
an eruption of papules upon the external surface of the lids, which appear 
several weeks after birth. Hutchinson^ describes a form of blepharitis 
in which sharp-bordered ulcerated plaques appear at the roots of the cilia, 
and instances in which absence or falling out of the eyelashes was a mani- 
festation of hereditary syphilis in children.'^ 

Treatment. — Locally the ulcer may be dressed with black or yellow 
wash, while internally the ordinary antis}^3hilitic remedies are to be ex- 
hibited. Especially efficacious is the employment of unguentum hydrar- 
gyrum spread upon flannel in the form of a binder. 



1 Syphilis und Auge, Wiesbaden, 1889. 

2 British Medical Joui-nal, 1863; ibid., 1885, ii. 62. 

* Edinburgh Medical Journal, September, 1888. 

* Hard Chancre of the Eyelids and Conjunctiva, Cincinnati, 1886. 
^ Memoires de la Societe Francjaise d'Ophtalmologie. 

« Ophthalmological Hospital Reports, ii. 2-58-283. 
' See also Barlow, quoted by Alexander, loc. cit. 



58 AFFECTIOXS OF THE EYELIDS, 

TUMOES AjSTD HYPERTEOPHIES OF THE EYELIDS. 

Milium. — Milia are small sebaceous elevations situated iu the skin, 
varying in size from a pin-point to a pea, and find their favorite seat in the 
forehead and about the eyelids. They are common in children about the 
age of puberty. They consist in an accumulation of sebum within the 
distended but closed sebaceous glands ; in this respect they differ from a 
comedo, in which the duct of the gland is patulous. They are caused by 
improper care of the skin, and may be connected with general constitutional 
disturbances, dyspepsia, and constipation. They should be opened with a 
knife or needle and the contents removed. 

Sebaceous Tumors (Atheroma) are not usually found upon the eyelid, 
but occur especially in the outer portion of the eyebrow. (See page 69.) 

MoLLUSCUM CoxTAGiosuM. — This is a disease of the sebaceous glands, 
or, according to some observers, of the rete mucosum, in which rounded 
papules, usually about the size of a pea, but often much smaller, appear 
in the skin of the eyelids. The common seat of the disease is upon the 
face, and especially the eyelids, but it often appears on the neck, breasts, or 
genitalia. Each little prominence may have the normal pinkish color of 
the skin, or it may be of a distinctly waxy hue, with a flattened summit 
which contains a depression. This disease, usually non-inflammatory, occurs 
chiefly among ill-nourished children, and may appear as an epidemic in 
homes and asylums. Two such epidemics have been well described by 
Mittendorf ^ The contagious nature of the disorder has been largely enter- 
tained, but so high an authority as Duhring^ denies that the evidence on 
this point is conclusive, while Neisser ^ believes that it is really an epithe- 
lioma contagiosum caused by a parasite belonging to the class of coccidia. 
The contents of tlie bodies is a yello\\'ish material which consists of fat and 
fatty epithelial cells. 

Treatment. — Each moUuscnm should be incised and the contents forced 
out. Nitrate of silver may be applied to the cavity, but this is not usually 
necessary. 

Ptosis Lipomatosa is an affection of the lids in which these drop over 
the cornea, owing to an abnormal accumulation of fat in the connective 
tissue. The deformity is considerable, and gives, the patient a disagreeable 
expression. The fat should be removed through a horizontal incision. 
In one case reported by Schell * seventy-one gi'ains were thus taken away. 
A reasonably good result may be anticipated ; but in a case recorded by 
Norris,^ although the removal of the fatty tissue improved the appearance 
of the patient, the levator palpebrarum failed to regain its power, and full 

' Transactions of the American Ophthalmological Society, 1886. 

■■' Diseases of the Skin, 2d ed. 

3 Vierteljahrschrift f. Dermatol, u. Syphilis, 1888. 

* Transactions of the American Ophthalmological Society, 1885. 

5 Ibid. 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 59 

activity in the movement of the upper lid was not secured. Care must be 
taken not to mistake oedema of the lid for a circumscribed tumor, an error 
readily avoided by palpation, which will reveal a characteristic difference in 
the resistance of the two affections. 

Angiomas (Nsevi) when they appear in the eyelids may exist either as 
simple bright red spots or in the form of cavernous growths. They are 
congenital tumors. It is important that they should be dealt with early in 
their existence, as they may take on rapid growth with the development 
of the child and extend far into the orbit. Such operative interference as 
promises the least subsequent deformity of the lid should be practised. 
When small, they may be readily excised ; if of the larger variety, some 
measure which destroys their blood-vessel structure will be the proper 
procedure. The methods employed are the galvano-cautery, which yields 
the best results ; injections of liquor ferri subsulphatis, a method which 
has been followed by sloughing of the lid ; and cauterization Math red-hot 
needles or with nitric acid. 

Plexiform Neuroma is an unusual form of tumor occasionally seen 
in the eyelid, consisting of a convoluted mass somewhat corded beneath the 
skin. In a collection from the literature of seventeen such cases four were 
noted as occurring in the eyelid.^ The growth is entirely benign in its 
nature, and its removal by an ordinary dissection with antiseptic precautions 
is unattended with difficulty. 

MoLLUSCUM FiBROSUM is a connective-tissue new growth, either sessile 
or pedunculated, situated beneath the skin. The tumors may appear singly 
or in great numbers all over the body, and occasionally are seen upon the 
eyelids. They are found at any time of life, but especially in childhood. 
In a remarkable case of this kind described by Michel the whole body was 
beset with these tumors, the largest of which grew from the upper lid and 
hung down below the lower eyelid. 

Sarcoma occurs as a primary tumor in both the upper and lower lids 
of children, and has been seen as early as the tenth month of life. It ap^ 
pears as a somewhat elastic growth, over which at first the integument is 
movable, but it tends to rapid growth, ulceration, and involvement of the 
orbit. As has already been pointed out (page 55), this growth may be mis- 
taken for a Meibomian cyst. Indeed, Samelsohu ^ has reported one instance, 
occurring in a child two years of age, which the microscope showed to be a 
sarcoma of the round-cell variety which had its origin in a proliferating 
tarsal cyst. The prognosis is grave. Thus, Van Duyse ^ has recorded a 
case of myxo-sarcoma in a seven-year- old child, which followed a contusion. 
After extirpation at the end of three months the local return required 
another operation. Four months later a second return developed, and the 



^ Unpublished Inaugural Dissertation, " Painful Tumors, with Special Keference to 
Neuromas," Prize Thesis, University of Pennsylvania, 1881. 
2 British Medical Journal, 1870, ii. 706. 
* Annales d'Oculistique, May and June, 1889. 



60 AFFECTIONS OF THE EYELIDS, 

whole orbit was cleared out ; in spite of which, a third return took place, 
and the tumor grew to the size of a child's head. Early excision, which 
is the only proper treatment, unfortunately, is not able in most instances to 
prevent the two chief dangers of this form of malignant tumor, especially 
in this region, — recidivity and metastasis. 

Lupus may secondarily attack the eyelids in its destructive march from 
a seat of origin in the face, and occasion ulceration of the lids, ectropion, 
or ankyloblepharon. 

Lepra, according to Michel, who quotes the observations of Carron 
du Villards, may appear in the eyelids among its earliest manifestations : 
Bull and Hansen ^ have observed the first symptoms in leprosy to be the 
falling out of the hair of the eyebrows, and E. Lopez ^ analyzed forty-five 
cases of leprosy and found absence of the eyebrows and lashes the sole 
ocular lesion in the youngest subject, ten years of age. 

Elephantiasis Arabum has appeared in the upper lid in consequence 
of an injury. C. du Villards saw this aifection in a seventeen-year-old girl 
on the left upper eyelid as the result of a contusion. Elephantiasis may be 
congenital. Van Duyse^ records an example in a girl of eight. 

Elephantiasis Teleangiectodes, or a disease which consists in an 
hypertrophy of the skin and the connective tissue, together with fatty tissue 
and distended vessels, has been observed in the upper eyelid as a congenital 
affection. Cases are on record by Pauli,* Von Graefe,^ Liston,^ and other 
observers.'^ The growth should be removed by the knife in such degree as 
is permissible with the preservation of the form of the lid. 

BLEPHAEOSPASM. 

Blepharospasm, or an involuntary contraction of the orbicularis, usually 
clonic, but sometimes tonic in its nature, is a constant symptom of diseases of 
the cornea and conjunctiva, and will be referred to again under these head- 
ings. According to Schubert,^ it may arise in the manner of a reflex action 
in individuals whose susceptibility is increased by hereditary influence, 
anaemia, over-exertion, etc., so that a slight irritation sends a stimulation to 
the facial branches of the orbicularis. Fissure at the angle of the lids is 
given by Koller ^ as a cause of reflex blepharospasm. As has been known 
since Von Graefe's historic case, a persistent lid-cramp occurs in children, 
unrelieved for weeks at a time, and when the eyes are finally opened there 
may be blindness, temporary in its character and with normal ophthalmo- 



1 Leprous Diseases of the Eye, 1873. 

^ Archives of Ophthalmology, December, 1889, p. 404. 

^ Annales d'Oculistique, t. ii., 1889. 

* Schmidt's Jahrbiicher, xxi, 84. 

= Klin. Monatsbl. f. Augenheilkunde, 1863. 

® Canstatt's Jahresbericht, ii. 153. 

■^ Consult Graefe u. Saemisch, Handbuch des Augenheilk., iv. 409. 

8 Miinchen. Med. Wochenschr., No. 28, 1887. 

^ Transactions of the American Ophthalmological Society, 1888. 



LACHRYMAT. APPARATUS, CONJUXCTIVA, AND CORNEA. 61 

scopic appearaDces, or loss of vision, permanent, and with gross changes iu 
the eve-ground. In a case recorded by Silex,^ a scrofulous child two and 
a half years old kept the eyes closed for twelve weeks, and was blind for 
twelve days, with normal ophthalmoscopic appearances, sight returning on 
the thirteenth day. The reporter argues in favor of the blindness being a 
species of cortical blindness, owing to the long absence of peripheral stimu- 
lation, Samelsohn,^ who among sixty thousand cases of eye-disease has ob- 
served five instances of blepharospasm lasting for months and followed by 
loss of sight, seeks for an explanation of the blindness which follows this 
long-continued cramp-like shutting of the lids, in an example of the forget- 
ting volition ( VergessemooUens) of the sensory perceptions analogous to the 
intentional suppression of the sense of sight of an eye in alternating stra- 
bismus. This explanation would apply only to such cases as have normal 
ophthalmoscopic appearances and recover, not to the instances of which 
Samelsohn has seen two, in one of which a true atrophy and in the other a 
glaucomatous atrophy was present. In these cases a peripheral cause must 
be sought for, and the theory of Von Graefe, which explained the blindness 
by the abnormal pressure of the lids, is applicable. 

Not infrequently children in their early school-days are affected with an 
undue winking of the eyelids, associated, perhaps, with jerky movements of 
the facial and other muscles. This is the form of nervous disorder which 
has been called habit chorea by Weir Mitchell,^ habit spasm by Gowers.* 
Almost invariably blepharitis, follicular conjunctival catarrh, and anomalies 
of refraction, usually hypermetropia, will be found to be the exciting causes. 
In a series of cases in my own practice the correction of the refraction-error 
and the treatment of the conjunctival disorder were productive of the most 
happy results, when tlie ordinary antichoreic remedies had proved valueless.^ 
In persistent forms of lid-cramp hypodermic injections of morphine will 
relieve the peripheral (trigeminus) irritation, and in stubborn varieties 
section of the supra-orbital nerve has been performed. The general condi- 
tion must be relieved by appropriate remedies. 

Lagophthalmos, or an inability to close the eyelids, as usually seen, 
is the result of paralysis of the facial nerve, but occurs also in connection 
with tumors of the orbit, in those rare instances of exophthalmic goitre 
which are seen in children, and with staphyloma. As a congenital defect, 
when the lids themselves are wanting and the entire orbit is divested of 
any covering for the bulb, the highest grade of lagophthalmos occurs. The 
cornea may suffer from ulceration, owing to exposure, — a danger greatly 
increased if with the affection of the facial nerve paralysis of the trigemi- 

1 Klin. Monatsbl. f. Augenheilkunde, February, 1888. 

2 Deut. Med. Zeitg., No. 15, 1888, and Centralblatt f. prakt. Augenheilkunde, Feb- 
ruary, 1888. 

^ Nervous Diseases, 2d ed., 1885. 

* A Manual of Diseases of the Nervous System, 1888. 

^ Transactions of the County Medical Society of Philadelphia, 1888. 



62 AFFECTIONS OF THE EYELIDS, 

nus also exists, but rendered less likely to occur in the single palsy, because, 
when the eifort to close the lids is made and during sleep, the eyeball is 
rotated upward under the upper lid, owing to the associated action of the 
superior rectus. 

Treatment. — In paralytic lagophthalmos the primary cause of the dis- 
order must be treated ; in the non-paralytic varieties and in any form in 
which the vitality of the cornea is threatened, the operation of tarsorrhaphy, 
which consists in uniting the margins of the upper and lower lids in the 
neighborhood of the external commissure, should be employed. 

AFFECTIONS OF THE CILIA AND CILIAKY BORDEK. 

Trichiasis, Distichiasis, Entropion. — Trichiasis is that condition 
in which the lashes are turned inward against the eyeball ; distichiasis, where 
incurved supplementary rows of cilia are developed from the intermarginal 
part close to the opening of the tarsal glands. The most usual cause for 
trichiasis in children is disease of the lid-border, — the various forms of 
blepharitis. Distichiasis in rare instances appears as a congenital aifection ; 
sometimes associated with other defects, as in the instance observed by 
Schweigger ^ where epicanthus and ptosis existed. The supplementary row 
of cilia is produced when the ordinary follicles are generated, although it 
is quite probable that in some instances the supernumerary lashes do not 
appear until the age of puberty, the extra hair-follicles having remained 
quiet until that time, now springing forth under the same impulse which 
the growth of hair elsewhere receives. 

Entropion, or inversion of the lid, is conveniently divided into mus- 
cular, organic, and the so-called bulbar entropion. The former variety is 
seen occasionally at birth, owing to undue development of the orbicularis, 
and is present as spasmodic entropion in conjunctivitis, keratitis, and when 
foreign bodies lodge on the cornea. By far the most common causes of 
organic entropion are granular lids and essential shrinking of the conjunc- 
tiva. It also follows diphtheritic ophthalmia. The bulbar entropion ap- 
pears when the eyeball is shrunken or even absent (anophthalmos), and 
there is consequent falling in of the lids. 

Treatment. — Trichiasis. — If not too numerous, the faulty lashes may 
be removed with a cilium-forceps, and when they reappear the procedure 
repeated. Destruction of the hair-follicles with galvano-puncture is recom- 
mended by Mitchell ^ of Missouri, Benson ^ of Dublin, and other surgeons. 
Strangulation of the roots of the incurved lashes, when only a few are out 
of order, may be accomplished by means of a fine subcutaneous ligature 
(Snellen) ; or complete removal of them by excision of the corresponding 
portion of the ciliary margin, a practice to be deprecated if the trichiasis is 
at all extensive. Finally, in severe cases, the whole ciliary border must 

1 Hand-Book of Ophthalmology, 1878. 

^ Klin. Monatsbl., April, 1882, quoted by Swanzy. 

» British Medical Journal, 1882. 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 



63 



be transplanted by either the single or double transplantation operations. 
Those most in vogue are the methods devised by Jaesche and modified by 
Arlt, and the double operations of Spencer Watson, Dianoux, Gayet, and 
others, or the more recently advocated method of Van Milligen,^ which 
consists in the transplantation of a piece of mucous membrane from the lip 
into the intermarginal space after the lid has been split. 

Entropion. — In temporary entropion good results may be obtained by 
painting the lid with collodion, which by its contraction draws out the 
inverted border, or by simply fastening this with a strip of plaster. The 
same effect may be obtained by pinching up a longitudinal fold of skin and 
muscle with a serre-fine and keeping it in place, occasionally changing the 
position of the instrument to avoid irritation. In spasmodic entropion ex- 
cision of a transverse fold of skin and muscle and stitching the edges to- 
gether may be practised, while in the organic forms more decided measures 
are necessary, and those most frequently employed are such as have already 
been referred to in connection with trichiasis ; in addition to which may be 
mentioned the Streatfeild-Snellen operation of grooving the tarsus, and the 
modifications devised by Green, Hotz, Berlin, Pauas, and other surgeons. 
(For the methods of performing these and all operations upon the lids, see 
pages devoted to describing operations.) 

Ectropion, or eversion of the lid with exposure of the conjunctival 
surface, occurs most frequently in the lower, but is also seen in the upper 



Fig. 2. 



Fig. 1. 





Ectropion the result of a wound from the 
tine of a fork. (Children's Hospital.) 



'-^"^X^Sfv? 



Ectropion of upper lid after injury to the 
brow. (Philadelphia Hospital.) 



lid. This may be partial, or there may be complete eversion with displace- 
ment of the puncta lachrymalia. The disorder is usually divided into the 
acute (e. musculare, e. spasmodicum) and the chronic form, or that which 
results from organic changes. The most usual causes of acute ectropion in 
children are ophthalmia neonatorum, and diseases of the cornea associated 
with blepharospasm, where the lids, during examination or in spells of cry- 
ing, become everted and remain so until replaced. One form of muscular 
ectropion is always seen in facial palsy, during which the lower lid is par- 
tially everted. The common causes of the second form of ectropion are 



^ Ophthalmic Keview, 1887, p. 309 ; also Centralblatt f. prakt. Augenheilkunde, July, 



1889. 



64 



AFFECTIONS OF THE EYELIDS, 



wounds, especially such as are produced by the laceration of dog-bites or by 
the lid being caught upon a sharp instrument, by burns and subsequent 
cicatricial contraction, by ulceration of the lids, and by caries of the orbi- 
tal border and the malar bone. 

Treatment. — This must vary according to the character and cause. In 
the spasmodic forms it is sufficient to replace by manipulation the everted 
lid and treat the conjunctival or corneal disease which caused the trouble. 
If there be eversiou of the punctum lachrymale, the canaliculus should be 
slit and the lachrymal passages probed. In the organic forms of ectropion 
a plastic operation which will relieve deformity and restore the lids to a 
normal position should be undertaken. A great variety of these procedures 
have been described and performed, but the plan adopted must be modified 
according to the existing deformity. Those commonly employed are such 
as include the vicious cicatrix in an excision, the remaining gaps being sup- 
plied by flaps taken from the surrounding tissue. Among these may be 
mentioned the methods of Adams, Wharton Jones, Arlt, and Richet. Com- 
plete destruction of the lid requires for its reformation a blepharo-plastic 
operation, which consists in the transplantation of a flap removed from some 
adjacent part to which it remains attached by its base, a method, however, 
which is being superseded by that introduced by Lefort and advocated by 
Wolfe, where a non-pediculated flap is taken from the arm to supply the 
defect. (See pages devoted to description of operations.) 

Symblepharox, or a cohesion between the eyelids and the ball, may be 
complete or partial. It occasionally occurs as a congenital defect, owing to 

an imperfect separation of the 
cutaneous folds which form the 
eyelids, on account of- failure in 
development of the ball or func- 
tioning of the eye-muscles. The 
most usual causes are injuries, es- 
pecially burns with acids or lime. 
Symblepharon also follows diph- 
theritic conjunctivitis, trachoma, 
pemphigus,^ and occasionally pur- 
ulent ophthalmia.^ The attach- 
ment may be merely slight bands 
between the conjunctival surface 
of the lid and ball, or the cornea 
also may be involved in the cicatricial union, in which case vision is mate- 
rially disturbed. It is the lower lid which is most usually involved in the 
process ; the upper may also participate (see Fig. 3). 

Ankyloblephaeox is that condition in which the borders of the tv\^o 




Symblepharon of upper iid following purulent 
ophthalmia. (Philadelphia Hospital.) 



1 Czermak, Wien. ^led. Wochenschr., 1888. 

2 University Medical Magazine, January, 1890. 



LACHRY3IAL APPARATUS, COXJUXCTIVA, AXD CORXEA. 65 

lids have grown together. This may be congeni-tal or acquired, aud, like 
symblepharou, either partial or complete. When merely the outer angles of 
the lids are involved, the disorder has received the name hlepharo-phimosis, 
while sometimes only the middle portions of the lid-borders are attached to 
one another, as, for example, in a case recorded by Von Hasner,^ where 
this attachment occurred in the form of a thread as a congenital defect. 
The same causes w^hich operate in the production of symblepharon are here 
active. Arlt ^ and Dujardin ^ have described varieties in which the vicious 
union was not due to a growing together of the lids, but probably to the 
organization of a membrane the result of croupous conjunctivitis. 

Treatment. — After an injury or a disease which is likely to be followed 
by one of these results, scrupulous care must be exercised to avoid the com- 
plication. During the formation of granulation-tissue this should be re- 
peatedly broken up with a probe, and adhesions occasionally may be pre- 
vented by introducing between the lids and the ball a piece of gold-beater's 
skin. If the attachments have formed and are slight, these may be cut 
through, and readhesion prevented in the manner just stated. In exten- 
sive symblepharon a formal operation must be done, and many methods 
have been devised, among the best of which may be mentioned Arlt's, in 
which the mass of adhesion is reversed, Teale's, where the raw surfaces 
left after the separation of the lid from the ball are covered by flaps from 
the neighboring healthy conjunctiva, and Prof. Wolfe's procedure of trans- 
planting rabbit's conjunctiva. In ankyloblepharon the adhesion should be 
divided with a fine knife. Blepharo-phimosis is corrected by canthoplasty. 
(See pages devoted to description of operations.) 

SuDDEX TuRXiXG Gray OF THE EYELASHES. — Sufficiently definite 
observations have shown that occasionally the hairs of the head can be 
deprived of their color suddenly, either universally or in places, forming 
locks of gray or white hair. Hirschberg * has recorded an instance in which 
the eyelashes of a girl, aged fourteen, turned white without apparent cause 
in fourteen days. The child formerly had been under his care for styes and 
phlyctenular disorders, but otherwise was in good health. The discoloration 
took place in the middle third of the upper lid, while in the under lid white 
bundles were commingled w'ith dark ones. I have seen an exactly similar 
case in a healthy, dark-haired young woman of eighteen. Within one week 
the middle portion of the cilia of the right upper eyelid turned perfectly 
white, while single white lashes alternated with dark ones in the lower lid. 
There was no reason to believe that this sudden change in color had been 
produced by artificial means.® 

1 Prag. Zeitschr. f. Heilkunde, 1881-2, ii. 429. 

^ Ophthalmological Society, Heidelberg, 1881 ; see Archives of Ophthalmology, vol. xvi. 

3 Eev. Clin. d'Ocul., November 5, 1886. 

* Centralbl. f. prakt. Augenheilkunde, January, 1888. 

* University Medical Magazine, March, 1889. Since writing this I have learned that 
the original color has returned to the eyelashes. 

Vol. ly.— 5 



66 AFFECTIONS OF THE EYELIDS, 

CONGENITAL DEFECTS OF THE EYELIDS. 

Congenital Ptosis. — This is not an uncommon affection, and may- 
be either unilateral or bilateral. The lid droops over the eyeball, and its 
edge covers the upper border of the pupil, its middle, or sinks still lower, 
but cannot be elevated above these points. Horner (Joe. cit.) has observed 
this affection in the first days of life, and has seen it in three generations 
of a family. It may be associated with limitation of the movements of the 
superior rectus, as well as with vices of conformation in other organs of the 
bodj. In a case under my own care ptosis of the left eye was combined 
with divergent squint from paresis of the internal rectus. The patient was 
six years old. The defect had been present since babyhood, and when the 
child attained the age of four he became the subject of epileptiform con- 
vulsions. The fundus of each eye Avas normal. Gunn^ has recorded a 
remarkable case of peculiar associated movements of the affected lid. When 
the jaw was moved to the right laterally, the left upper lid was raised, or, in 
other words, there was contraction of the levator palpebrse in connection 
with the external pterygoid.^ 

Under the name ectopia tarsi J. T. StreatfeilcP has described, as a 
congenital defect, a sloped condition of the palpebral fissures, the lids being 
apparently drawn down Avholly and evenly at the inner or nasal side. 

Etiology. — Ptosis usually is divided into two varieties, — one in which 
a positive hypertrophy of the connective tissue exists, and one in which 
the drooping is due to absence or imperfect development of the levator 
palpebrarum, or to paralysis of this muscle. Its presence also has been 
attributed to the pressure of the forceps during birth, a cause \vhich Hor- 
ner denies, inasmuch as this affection is seen during the first days of life 
without any mark of the instrument upon the face of the child, and because 
it occurs through several generations of one family. It furthermore fre- 
quently is associated with other congenital defects. Ptosis the result of 
paralysis of the oculo-motor nerve is referred to on jjage 135 of this volume 
(article on diseases of the eye). 

Treatment. — It is usual to attempt to remedy this defect by the removal 
of an elliptical piece of skin. To avoid the risk of shortening the lid which 
attends this operation, methods have been devised for producing cicatricial 
bands by means of subcutaneous sutures passed from the brow to the tarsus. 
Among these may be mentioned the plans of Bowman, Pagenstecher, De 
Wecker, and the more recently devised method of Panas. 

Epicanthus. — Von Ammon * gave this name to a somewhat rare af- 

1 Transactions of the Ophthalmological Society of the United Kingdom, London, 1883, 
iii. 283-287. 

2 See also a paper by 0. Bull, Archives of Ophthalmology, 1888, vol. xvii., on " Syn- 
chronous Movements of the Upper Lid and Maxilla." 

^ Ophthalmological Hospital Reports, 1874-76, vol. viii. 

* Klinische Darstellungen der Krankheiten und Bildungsfehler des menschlichen 
Auges, Berlin, 1838. 



LACHRYMAL APPARATUS, COX.TLTXCTIVA, AND CORXEA. 



67 



Fig. 4. 




Epicanthus. (After Von Amnion.) 



fection in which, owing to au excessive development upon the bridge of the 
nose, a fold of skin passes from the inner end of the brow to the side of 
the nose and covers the internal 
canthns. It is usually bilateral, 
and generally associated with 
congenital ptosis. 

Horner {loe. cit.) has pointed 
out that an examination of this 
reffion in new-born children 
might readily lead to the belief 
that a low grade of epicanthus 
was very common. This, how- 
ever, lessens and disappears as 
the child develops. The fact 
that the free border of the abnormal fold of skin nearly covers the sclera 
gives rise to an appearance as if convergent squint was present. 

Etiology. — Von Graefe ^ believed that epicanthus depended not so much 
upon the development of an abnormal fold of skin as upon insufficiency 
of some of the twigs of the oculo-motor nerve, and Hirschberg^ has 
demonstrated a connection in one case between epicanthus and ophthalmo- 
plegia, in which the defect appeared to be due to a congenital aplasia of 
the gray nuclei .below the aqueduct of Sylvius, while Manz ^ has sought 
for a common origin of this and similar anomalies in the development 
of the bones of the face which are concerned in this region. The ab- 
normality may appear in several members of the same family. Under 
the name epicanthus exterims a somewhat analogous affection has been de- 
scribed in which the fold of skin was observed to cross the outer angle 
of the eye. 

Treatment. — The usual method for the relief of this deformity is to 
excise a piece of skin from the bridge of the nose, with or without a can- 
thoplasty, according to the circumstances. It is important to obtain firm 
primary union, lest, as has been pointed out by Knapp, the subsequent 
stretching result in unsightly scars. Arlt has obtained good results from 
the excision of the vertical fold of skin itself. I have seen an interesting 
case of partial epicanthus associated with a mole growing over the bridge 
of the nose, in which Dr. W. F. Norris effected a good result by excising 
the mole and covering in the skin-deficiency with a flap taken from the 
forehead. 

CoLOBOMA OF THE Eyelids appears in the form of a fissure which 
may be confined to the upper lids, either one or both, but which also has 
been noted in the lower lids and even in both upper and lower lids. 

^ Quoted by Manz, Graefe u. Saemisch, Handbuch der gesammten Augenheilkunde, 
vol. ii. 

2 Neurolog. Centralbl., 1885, No. 13. 

^ Graefe u. Saemisch, Handbuch der gesammten Augenheilkunde, vol. ii. 



68 AFFECTIONS OF THE EYELIDS, 

In the observations of Dor ^ of Lyons, and Jules Nicolin,^ in twenty- 
seven instances a single eyelid was involved, twice the two eyelids of the 
same eye, sixteen times one lid of each eye, and once the deformity appeared 

Fig. 5. 




Coloboma palpebrarum. (After Manz.) 

on all four lids. In the majority of instances the defect is found in the 
upper lids, — accordiug to D'Oench,^ twenty-three times in thirty-three 
cases. Coloboma of the eyelids may exist as a single malformation, but 
more frequently has been seen in conjunction with hare-lip (fourteen times 
in forty-seven cases), absence of the lachrymal puncta, dermoid tumors 
of the cornea, and clefts of the iris, pharynx, lip, and nose. 

Etiology. — Many theories have been advanced to explain this anomaly : 
a primordial defect of organization ; the action of amniotic strands (Van 
Duyse) ; heterotopic tissue- formation (Manz) ; intra-uterine inflammation 
(Osio) ; an arrest of development, owing to the failure of the joining of 
the two halves of the first branchial arch together with the frontal promi- 
nence (Nicolin and Dor). 

Treatment. — This consists in freshening the edges of the gap and 
uniting the opposing surfaces by sutures. The extent of each deformity and 
its relation to the cornea necessarily determine the character of operation 
which must be undertaken. 

Absence of the Lids. — Sometimes children are born with complete 
or partial absence of the eyelids, — ablepharia totalis and partialis, or con- 
genital lagophthalmos. At other times the eye is hidden, owing to an adhe- 
sion between the eyelids, and we have the condition to which Manz {l,oe. 
eit.) has given the name cryptophthalmos, a term which, as Van Duyse * 
has observed, should be preserved for those cases where the exterior 
integument passes in front of an eye more or less developed, — that is, 
where there is complete absence of the lids and palpebral fissure. It is a 
congenital anomaly of extreme rarity. Fuchs ^ has reported two cases of 
abnormal shortness of the lids so that the patients could close them only 
with the strongest pressure, and Pfliiger has observed an instance of ab- 

1 Kevue Generale d'Ophtalmologie, December, 1888. 
^ Du Colobome congenital des Paupieres, Lyons, 1888. 
3 Archives of Ophthalmology, vol. xv. 
* Annales d'Oculistique, January-February, 1889. 
^ Archiv f. Augenheilkunde, xv. 2. 



LACHEYMAL APPAEATUS, COXJUXCTIVA, AXD COEXEA. 69 

normal length of the fissure of the lids where complete closure was pos- 
sible only by the greatest effort. Ectropion was not present. Tarsorrhaphy 
produced a cure in the first case. 

Symblepharon, ankyloblepharon, and distichiasis also occur as congenital 
anomalies, and have been described. A rare defect is complete absence of 
the eyelashes. 

DISEASES OF THE EYEBKOW. 

The eyebrow may be involved in any diseased process which attacks the 
neighboring skin or the scalp ; and no separate description of injuries or 
diseases of the skin, especially seborrhoea and eczema, which are prone to 
attack this region, need be appended. 

Two forms of cystic growth affecting this area are seen in children. Se- 
baceous cysts (atheromatous cysts) frequently appear as congenital growths 
upon the outer portion of the eyebrow, and may reach a considerable size. 
They are deeply situated, and not infrequently attached to the periosteum 
of the orbital margin. A cyst of this character takes its origin in the seba- 
ceous follicles of the region. Dermoid cysts exist as painless, spheroidal 
growths, most frequently at the outer angle of the orbit on a level with the 
eyebrow, less usually at the inner angle above. When in the latter situa- 
tion, it is possible to mistake the affection for a meningocele which may 
have a similar situation. As Juler ^ has pointed out, the meningocele can 
be emptied on pressure, has a slight impulse, and is not movable, — diag- 
nostic points which do not obtain in the case of the dermoid cysts. The 
structure of a cyst of this kind is composed of the elements of the skin. 

The treatment is the same for both classes of cysts, and consists in extir- 
pation through an incision made parallel to the border of the orbit, care 
being taken not to rupture the sac-wall. It ought to be remembered in the 
excision of these gro^iihs that sometimes they are attached firmly to the 
periosteum, and that they may even erode the bone and extend far into the 
orbit. 



AFFEOTIOI^S OF THE LAOHETMAL APPA- 
RATUS. 

Statistics show that affections of the lachrymal apparatus are less 
common among children than among adults. In Horner's list diseases of 
this svstem among children are set down as constituting one and sixteen- 
hundredths per cent. Among seventeen hundred and eight recorded cases 
at the Children's Hospital in Philadelphia one and one-tenth per cent, 
exhibited affections of the lachrymal apparatus. Diseases of the lachry- 
mal structures naturally divide themselves into those which have their seat 

1 Ophtlialmic Science and Practice, 1884:. 



70 AFFECTIOXS OF THE EYELIDS, 

in the lachrymal gland, and those which affect the drainage-system, — i.e., 
the puncta canaliculi, lachrymal sac, and nasal duct, 

Daceyoadexitis, or an inflammation of the lachrymal gland, is com- 
paratively a rare affection, and may be either acute or chronic. Hirsch- 
berg,^ among twenty-two thousand five hundred cases, found only one 
instance of suppurative dacryoadenitis. He reports a case of acute, non- 
suppurative dacryoadenitis in a girl of fifteen, which on account of its 
analogy to bilateral parotitis he called " mumps of the lachrymal gland." ^ 
The chronic — especially, according to Ivnapp,^ the monolateral — form is 
more common, and has been observed among scrofulous children, and may 
be caused by an injury or follow diseases of the conjunctiva and cornea. 
If the gland is chronically enlarged, jjalpation will reveal its lobulated 
border ; if the inflammation is acute, there are pain, tenderness, and swell- 
ing at the upper and outer part of the eyelid, with chemosis of the conjunc- 
tiva beneath. This may go on to suppuration, and the abscess usually points 
upon the skin, but occasionally through the conjunctiva. 

Treatment. — Warm applications and poultices to relieve the pain, and 
at the first appearance of pus early incision, either through the integument 
parallel to the eyebrow or through the conjunctiva, must be practised. If 
induration of the gland occur, this is to be treated locally with iodine or 
inunction of iodide-of-cadmium ointment. 

Fistula of the Lachrymal Glaxd may remain on account of the 
rupture of an abscess, but has also been recorded as a congenital defect, — for 
instance, in Steiuheim's^ case, mentioned by Horner (loc. cit.), which was 
situated at the outer third of the upper lid, one-third of an inch from the 
ciliary margin, and surrounded by a tuft of hair. This may be closed by 
repeated cauterizations, by a plastic operation, or, in the event of failure, 
by extirpation of the gland. 

Dacryops is an unusual affection caused by a cystic distention of one 
of the gland-ducts, and may be recognized by the presence of a bluish, 
translucent swelling beneath the conjunctiva at its upper and outer part. 

Hypertrophy of the Lachrymal Gland has been observed at 
birth, but usually is seen in later years, and consists in an indurated, lobu- 
lated tumor. 

Spontaneous Prolapse of the Lachrymal Gland in the form of 
a soft movable tumor under the upper lid has been described. In a case 
recorded by Noyes^ this condition was found in a girl of twenty, who for 
nine years had a swelling beneath the upper lid of this character, which 
on removal proved to be the lachrymal gland itself. The treatment is 
extirpation of the prolapsed organ. 

1 Archives of Ophthalmology, 1879, viii. 370. 

^ See, also, Centralblatt f. prakt. Augenheilkunde, 1890. 

^ Transactions of the American Ophthalmological Society, 1884, vol. iii. 

* Klin. Monatshl., xiii. 302; also Ophthalmological Hospital Keports, vol. viii. 

= Transactions of the American Ophthalmological Society, 1887. 



LACHRYMAL APPARATUS, COXJUXCTIVA, AXD CORXEA. 71 

Syphilis of the Lachrymal Glaxd. — The lachrymal glaud is sin- 
gularly free from syphilitic affectious, but specific inflammation has been 
described by Streatfeild ^ and others in adults, the inflammation subsiding 
under antisyphilitic remedies. Albini ^ observed in a syphilitic young 
woman a tumor of the lachrymal gland which was composed of glan- 
dular elements, organized connective tissue, giant cells, but no Lustgarten 
bacilli. ' 

Tumors of the Lachrymal Glax^d. — The several varieties of benigru 
and malignant growths which have their seat in glandular tissue have been 
seen in the lachrymal gland. Samelsohn^ found in a child three and a 
half years old a lithiasis of the gland, the concretion proving to be an 
osteochondroma. Snell* has seen an adenoma in a girl of eight, and I 
have recorded a similar instance in a young man, a patient of Dr. D. 
Hayes Agnew, who removed the growth.^ Power ^ had a sixteen-year-old 
patient with encapsulated fibro-sarcoma. Tubercle has been discovered in 
this region, as, for instance, in a case reported by Abadie,^ where the gland 
of a girl aged sixteen was found to be tuberculous. Excision of the growth 
in all instances is the only treatment. 

AXOMALIES OF THE PUXCTA LaCHRYMALIA AXD CaXALICULI. As 

congenital anomalies double puncta lachrymalia and canaliculi have been 
observed, as in the cases recorded by Mooren, Galezowski, Horner, and 
others, while Emmert and Fieuzal have seen congenital absence of these 
structures, and Von Reuss,^ in a boy aged twelve, noted the absence of all 
four lachrymal points, while the papillae were present and the canals were 
represented in the lower lid by furrows ; in the upper lids they were 
wanting. 

The slightest change in the natural relation of the lower punctum to 
the eye, against which it is directed backward, causes epiphora, or an over- 
flow of tears.^ The most fruitful sources of such abnormal relationship 
are the various chronic inflammations of the lid and conjunctiva, — blepha- 
ritis, granular conjunctivitis, and ectropion ; and facial palsy and wounds 
of this region. In facial paralysis watering of the eye is sometimes the first 
symptom noted, and is caused partly by the loss of compressing power in 
the lid, especially in the fibres of Horner's muscle, and partly by the falling 
away of the punctum. Epiphora further results from the presence of a stye 

1 British Medical Journal, 1882, ii. 633. 

^ Ann. di Ottalm., vol. xvi., 5-6, p. 501. 

^ Centralblatt f. prakt. Augenheilkunde, December, 1880. 

* Ophthalmic Eeview, 1889. 

^ Transactions of the Pathological Society of Philadelphia, xii. 238. 

^ Transactions of the Ophthalmological Society of the United Kingdom, 1882, vol. ii. 

^ Archives d'Ophtalmologie, 1880, p. 432. 

8 Wiener Med. Presse, 1886, No. 7. 

^ Epiphora, strictly speaking, is an excessive secretion of tears, while stillicidium 
lachrymarum is an overflow from obstruction ; but, as Mr. Nettleship remarks, no useful 
purpose is served by keeping the two names. 



72 AFFECTIONS OF THE EYELIDS, 

or tumor of the lid near the puuctum, or, if the canalicuhis is closed, by the 
presence of a foreign body like a hair, usually a cilium, a mass of fungus 
(leptothrix),^ a so-called tear-stone, as in a case of Kipp,^ or even, as PauP 
has recorded, by the development of a polyp. Finally, an overflow of 
tears may follow an abnormal position of the caruncle, as in the observa- 
tion of Horner {Iog. ait), where in a five-year-old child this was so mis- 
placed as to be situated below the lower punctum upon the inner surface of 
the lid, which was pressed away from the eyeball. Enlargement of the 
caruncle, as Von Graefe observed, may produce a like symptom, and its 
removal has been followed by the disappearance of the difficulty. 

Treatment. — In cases of epiphora without disease of the lachrymal sac 
or stricture of the nasal duct, a simple slitting of the canaliculus is usually 
sufficient. If a foreign body is present, this should be removed. This 
treatment does not apply to cases of facial palsy. 

Anomalies of the Lachrymal Sac and Nasal Duct. — Among 
children about one-third of the cases of lachrymal affections belong to the 
acute form of diseases of the sac ; Horner (loc. cit.) states that this occurs 
in from thirty-six to forty-eight per cent. Dehenne * has reported a case 
of congenital tumor of the lachrymal sac which appeared in the form of 
an abscess. Terson and Galezowski ^ have observed similar examples, the 
latter surgeon having successfully treated his cases by injections of water. 

Dacryocystitis. — The universal symptom in affections of the lachrymal 
sac and duct is epiphora. The eye swims in tears, and these are excited to 
overflow by exposure to dust, cold, or wind. The caruncle and plica are 
swollen, the neighboring conjunctiva hypersemic and injected, — the lachry- 
mal conjunctivitis of Galezowski, — the skin macerated, and the margins of 
the lids, especially nasal-ward, show signs of blepharitis. Pressure upon 
the region of the lachrymal sac, which may be distended (mucocele, lachry- 
mal tumor), expresses through the puncta the retained fluid, which is a 
clear or semi-transparent viscid mucus (dacryocystitis catarrhalis), or turbid 
from admixture with purulent material (dacryocystitis blennorrhoica). The 
lachrymal sac thus chronically distended is liable at any time to take on a 
suppurative inflammation, producing acute dacryocystitis, which may be 
preceded by fever and chill; the lids and region of the nose become 
tender to the touch and tense with a red and brawny swelling, resembling 
erysipelas, for which it not infrequently has been mistaken. When there 
is added to disease of the sac a phlegmonous inflammation of the cellular 
tissue (dacryocystitis phlegmonosa) which surrounds it, the pus burrows in 
front of the sac, forms pouches in the connective tissue, and in most in- 

1 Consult Goldzieher, Centralbl. f. prakt. Augenheilkunde, 1884, p. 33, and A. v. 
Reuss, Wiener Med. Presse, 1884. 

2 New York Medical Record, xxiv. 289. 

3 Quoted by Scliirmer, Graefe u. Saemisch, Handbuch, a^oI. vii. 
* Recueil d'Ophtalmologie, 1883, p. 122. 

5 Ibid. ; also Archives of Ophthalmology. 




LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 73 

stances the lachrymal abscess points below the tendo oculi. If unmolested, 
the abscess ruptures externally, with the formation of a fistulous opening 
into the sac, the mouth of which is surrounded by pouting granulations. 

Obstruction of the nasal duct, which gener- 
ally antedates the affection of the sac, may be ^• 
situated at any part, but is usually found at its 
upper end. In the early stages of the catar- 
rhal dacryocystitis there is probably no true 
stricture of the duct, but the flow from the sac 
into the nose is prevented by swelling of the 
mucous tissue ; later, and in other instances, 
dense cicatricial strictures occur. The most 
impermeable obstructions follow injuries, — 

,1 1 r> 1 • 1 J.U Ti tj. Phlegmonous dacrj oc\ btitis (Chil- 

the rough use oi bougies, and the like. It dren's Ho'^pitai ) 

must not be forgotten that stoppage of the 

lachrymo-nasal duct may be caused by pressure from neighboring tumors, — 
e.g., in the antrum of Highmore, — or by foreign bodies, as in the curious 
case recorded by Haifner,^ where a lumbricoid worm three centimetres long 
and one millimetre thick occupied the left lower lachrymal canal. 

Fistula of the Lachrymal Sac. — This occasionally has been observed as 
a congenital anomaly. It may be present only on one side, as in the case of 
Schreiber,^ where in a child ten weeks old the orifice was directly under the 
internal palpebral ligament, or on both sides, as in the instance reported by 
Agnew.^ Usually a. fistulous opening into the sac is caused by the rupture 
of a lachrymal abscess, and Parinaud * has seen this result from a carious 
condition of the upper canine tooth. The opening may appear about one 
centimetre below the punctum, but also in various spots along a line which 
runs outward parallel to the lower orbital border. It usually communicates 
with the sac, but, as Rampoldi has reported, the opening may lead into 
the lower canal only, the sac above being shrunken. Pus or muco-pus, 
and later the tears, which should descend into the duct, exude from the 
opening, which for a long time persists as a fine orifice, at the mouth of 
which appears a drop of clear fluid. This is the so-called capillary fistula. 
The condition is to be differentiated from a buccal fistula below the margin 
of the orbit, which, according to ScheflF,^ may be done by observing that in 
the latter the situation is never accurately at the orbital margin, but from 
one-eighth to one-fifth of an inch below, that a sound never passes upward, 
but only downward, laterally or posteriorly, and that the secretion is always 
purulent. 

Pre-lachrymal Abscess. — As has been especially pointed out by C. S. 

1 Berlin. Klin. Wochenschr. , No. 24, 1880. 

^ Jahresber. d. Augenheil.-Anstalt in Magdeburg, Nagel's Jahresbericht, 1885. 

^ Transactions of the Ophthalmological Society, 1874. 

* Bull, et Mem., de la Soc. de Chir. Paris, ix. 180. 

5 Wien. Med. "Wochenschr., No 12, 1888; Medical News, October 13, 1888. 



74 AFFECTIONS OF THE EYELIDS, 

Bull/ a swelling may exist above the internal palpebral ligament and a little 
external to the region of the lachrymal sac, associated with a fistulous 'open- 
ing from which pus flows, having no connection with the sac itself. In 
his case this pre-lachrymal abscess was caused by a blow from a cane at 
the inner angle of the eye, and was associated with caries and perforation 
of the lachrymal bone. The same condition I have observed in children 
without injury, the subjects of hereditary syphilis. The condition is to be 
distinguished from a true lachrymal abscess by the fact that there is no 
interference with the passage of the tears from the conjunctiva into the sac, 
by the pain on pressure, and by the absence of acute inflammation. The 
treatment is that of an abscess, together with such constitutional measures 
as may be indicated by the dyscrasia of which the patient is the subject. 

Etiology of Diseases of the Lachrymal Sac and Duct, — Disease 
of the lachrymal sac rarely is primary. In young infants dacryocystitis, 
often double, arises without apparent cause. Kipp ^ found during two years 
three and six-tenths per cent, of lachrymal diseases, and six per cent, of 
these were under one year of age, the affection even having been seen 
shortly after birth. In the majority of cases bleunorrhoea of the sac is 
caused by retention of the secretion from stricture or obstruction in the 
nasal duct and participation of the lining of the sac in an inflammation of 
the naso-pharynx. In other instances strictures result from, rather than 
cause, blennorrhcea. The proper appreciation of the pathological conditions 
of the nasal mucous membrane in relation to diseases of the lachrymal appa- 
ratus, and as an etiological factor, is of the utmost importance. This rela- 
tionship has been especially dwelt upon by Harrison Allen,^ Nieden,* Ziem,^ 
Gruening,^ and Grut.^ Although it might seem natural that conjunctivitis, 
especially purulent conjunctivitis, should cause lachrymal disease, this is 
by no means frequently the case. Horner (Iog. dt.) in one instance only was 
able to observe a bleunorrhoea of the sac arise from a similar inflammation 
in the conjunctiva ; and conjunctivitis and blepharitis, so constantly accom- 
panying disorders, follow rather than cause the lachrymal affection. Ob- 
struction of the duct and disease of the sac follow measles, scarlet fever, 
and especially variola, because these exanthemata are accompanied by in- 
flammation of the nasal mucous membrane. Periostitis and caries of the 
lachrymal bone, the result of syphilis, are important causes. Gummy 
growths may block the sac (osteo-periostitis gummosa of Panas) and go on 
to rapid suppuration. The relation between asymmetry of the face and 
disease of the naso-lachrymal duct deserves mention. Finally, traumatism 

^ American .Journal of the Medical Sciences, 1880. 

'^ Transactions of the American Ophthalmological Society, ii. 537. 

3 Medical News, February 6, 1886. 

* Archiv f. Augenheilkunde, xvi. 381. 

5 Centralblatt f. prakt. Augenheilkunde, 1886, S. 222. 

« Medical Kecord, 1886, xxix. 

' Hospitalstid, Nos. 21 and 22, 1865, — abstract. Archives of Ophthalmology, vol. xv. 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 75 

accounts for certain cases. Fistulas, especially those seen in infants, not 
infrequently depend upon disease of the bones, which iu turn is the result 
of inherited syphilis. 

Prognosis in Lachrymal Disease. — The well-known fact that under 
the most skilful treatment affections of the tear-passages often resist healing 
may render a guarded prognosis necessary. This depends entirely upon 
the condition of the nasal chambers, the duration of the malady, the per- 
meability of the stricture, and the cause of trouble. When the latter is 
the result of injury, the prognosis becomes especially grave, and the malady 
may be irremediable. 

Treatment. — Manifestly, the success of all treatment centres upon the 
restoration of the calibre of the duct, if this be strictured, and the relief of 
the most important cause of the disease of the sac. Occasionally it suffices, 
especially in new-born children, to dilate the punctum and wash out the sac 
with a fine Anel syringe and an antiseptic solution. Usually three pro- 
cedures are necessary, — slitting up the canaliculus, introducing the probe 
into the nasal duct, and washing out the sac and naso-lachrymal duct with 
an appropriate syringe. 

The slitting of the c^niculus is best done with a Weber's knife, 
which is introduced, the lid being dra^vn down and out with the thumb, 
until the probe point of the instrument touches the inner wall of the lach- 
rymal sac. It is then raised to the vertical line with the cutting blade 
turned slightly inward, and the roof of the canaliculus thus divided. The 
lower canal is most frequently chosen. Some surgeons, as a rule, split the 
upper canaliculus ; if there is much distention of the sac (mucocele), a good 
plan is to enter the upper passage and to incise both this and the wall of 
the sac. The probe (Bowman's probes are the best, though useful modifi- 
cations have been devised by Theobald and Tansley) is now introduced 
along the canaliculus until its point touches the lachrymal bone. It is then 
raised to the vertical position and pushed into the duct, remembering that 
the direction is downward, slightly backward, and outward. Undue efforts 
should never be employed. If the stricture resist, recourse may be had 
to dividing this with a knife, either the one which has been employed iu 
slitting the canaliculus, or, still better, the specially-devised instrument of 
Stilling. The duct and sac should now be washed out thoroughly with a 
lachrymal syringe and some antiseptic fluid, either a saturated solution of 
boracic acid, or a one to five-thousand solution of bichloride of mercury. 

It is advisable to make the first trial with a No. 2 Bowman probe ; if 
this fails, a smaller one may be tried. Either rapid or gradual dilatation is 
employed, the latter being the preferable method. The sound should be 
used at first every second or third day, but as the case progresses longer 
intervals may elapse. Theobald has recommended the introduction of very 
large lachrymal probes, a method not always applicable, owing to the great 
diversity in the size of the bony duct. The whole treatment often occupies 
months. 



76 AFFECTIOXS OF THE EYELIDS, 

If a lachrymal abscess supervenes, and is seen early, the canaliculus 
should at once be slit, and, if possible, the secretion evacuated, with reten- 
tion of the passage into the nose. Frequently the pain and swelling are 
such as to render this impossible, and the opening must be made upon the 
face about one centimetre below the palpebral tendon, cutting downward 
and outward. In the highly inflammatory stage, probing must not be 
employed, but the sac and abscess-cavity should be freely irrigated with a 
solution of bichloride of mercury. An excellent practice is to use hot com- 
presses over the swelling, preferably of carbolized water of a temperature of 
120° F., frequently changed, and applied for five or ten minutes at a time. 
Later, the restoration of the passage into the nose must be undertaken by 
probes in the manner already described, but if the patient is refractory, 
which is almost invariably the case in young children, excellent results will 
follow the introduction of a style made of lead wire, slightly hooked over 
the inner cauthus to prevent its slipping into the sac. 

Swelling over and around, together Avith fistulous connection into, the 
lachrymal sac, occasionally will subside under the judicious use of a com- 
pressing bandage. I have tried this method, again recently advocated by 
Bothen ^ and others, quite often in the Children's Hospital and in the 
Philadelphia Hospital, with very good results. My plan is to put a grad- 
uated compress of iodoformated cotton over the swelling, securing it firmly 
with a roller bandage. 

In addition to the local measures already mentioned for the purpose of 
producing healing in case of lachrymal disease, weak solutions of nitrate of 
silver, salicylic acid, iodoform, and creolin, with which latter drug I have 
had but indifferent success, have been advocated. In case of acute inflam- 
mation with abscess-formation, quinine, and iron in the form of Basham's 
mixture, are indicated ; in syphilis with disease of the bone and gummatous 
deposit, the usual remedies are to be exhibited, and the best of these in 
children is the mercury binder ; in struma, cod-liver oil, hypophosphites, 
and iron in the form of the syrup of the iodide are the most trustworthy 
remedies. Scrupulous attention to the nose and naso-pharynx is neces- 
sary, and any local lesions which present themselves must be treated. In 
the absence of a special line of treatment for this region, I have achieved 
excellent results by simply spraying out the parts with Dobell's solution 
and listerine, while carrying on the regulation measures for the relief of the 
lachrymal disorder. 

If a fistula remains, this may be healed at times, as already stated, by 
compression. In the event of failure, freshening the edges and the galvano- 
cautery may be tried, the surrounding pouting granulations being removed 
by scraping. The capillary fistulas are productive of no inconvenience, and 
may be allowed to remain undisturbed. In stubborn cases which have 
resisted all reasonable treatment, extirpation of the lachrymal gland has 



1 Centralblatt f. prakt. Augenheilkunde, Supplement, 1887. 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 77 

been done, as was originally recommended and performed by Lawrence, or, 
as more recently has been advocated by De Wecker, excision of its palpebral 
portion, or the lachrymal sac may be obliterated by means of caustics. 
Under judicious treatment, the necessity for these somewhat heroic meas- 
ures ought not to arise. 

Character of the Lachrymal Secretion under Pathological 
Conditions. — The lachrymal sac is a reservoir for the fluid secreted by the 
conjunctiva, and, this fluid being more or less loaded with micro-organisms, 
if stopped by stricture of the duct the sac becomes stuffed with micrococci. 
Widmark^ found in dacryocystitis streptococcus pyogenes, which by in- 
oculation caused phlegmonous inflammation. If the cornea is abraded, or 
if a solution of continuity in this membrane is necessary by operation, the 
presence of pathogenic organisms in the fluid becomes a serious complication. 
These may turn a simple abrasion into a sloughing ulcer and an aggravated 
hypopyon keratitis ; they may forbid the healing of an ordinary keratitis ; 
and, finally, they may inoculate an operative wound and defeat the object 
of the operation. For this reason it is most important that in any of the 
three cases just quoted the permeability of the nasal duct should be ascer- 
tained ; if it is strictured it should be opened, and the walls of the lachry- 
mal sac, if inflamed, as speedily as possible brought into a healthy condition. 
The importance of this relation of the lachrymal apparatus to diseases of 
the cornea will be again referred to in the section devoted to the considera- 
tion of the latter affection. 



DISEASES OF THE OOl^JUl^OTIYA. 

The great frequency of diseases of the conjunctiva and cornea during 
childhood — according to Horner, half of all the affections of the eye during 
this age of life belong to this group — sufficiently emphasizes the impor- 
tance of the sul)ject. Nearly sixty-three per cent, of the patients wiio have 
applied at the Eye Dispensary of the Children's Hospital during the last 
nine years have come on account of one or other of the types of corneal or 
conjunctival affection, in thirty-six and a half per cent, of the cases the 
lesion belonging to the conjunctiva alone. 

The most important group of diseases of the conjunctiva includes the 
inflammations, to which the general term ophthalmia may be applied. 

OPHTHALMIA NEONATOEUM. 

Synonymes. — Purulent ophthalmia, Gonorrhoeal ophthalmia, Blennor- 
rhoea of the conjunctiva, Purulent conjunctivitis. 

Definition. — This is an inflammation of the conjunctiva characterized 



Hygeia, 1887, abst. from Centralblatt f. prakt. Augenheilkunde, July, 1887. 



78 AFFECTIONS OF THE EYELIDS, 

by great swelling of the lids, serous infiltration of the conjunctiva, and the 
free secretion of contagious pus. 

Etiology. — The prevailing opinion is that this affection is caused by 
the introduction into the eye of the infecting material from some portion of 
the genito-urinary tract of the mother at the time of or shortly after birth. 
It is equally well ascertained that the majority of cases and all severe forms 
are due to the presence of the gonococcns of Neisser. Exceptionally inocu- 
lation appears to have taken place in utero. Magnus ^ reports an instance 
of ophthalmia neonatorum, with involvement of the cornea, of such origin, 
where the membranes were ruptured three days before birth and permitted 
the entrance of the gonococci. Fuchs^ has observed in a child at birth per- 
foration of the cornea as the result of congenital ophthalmia. A high degree 
of penetrating power is ascribed to this special micro-organism by Mules,^ 
who has seen an infant born at the seventh month after an exceptionally 
easy labor with well-marked ophthalmia neonatorum. The child was 
brought eight hours after delivery, exhibiting the symptoms of the second 
stage of the disease : so that infection in utero must have occurred at least 
two days before birth or rupture of the membranes. 

The gonococcns is generally, although, according to Widmark* and 
Weeks,^ not invariably, present in the secretion, being specially numerous 
during the muco-purulent stage. According to Cohn, two varieties of 
ophthalmia neonatorum may be distinguished, — a severe type, supplied 
with the micro-organism, with a tendency to increase in severity and in- 
volve the cornea ; and a milder type, non-specific, with a tendency to 
recover. 

The presence of a virulent vaginal discharge in the mother is not neces- 
sary to produce this condition, as it probably may arise from the introduction 
of any muco-purulent discharge during the birth ; while careless bathing 
of the child after birth and the use of soiled towels and sponges are fruitful 
sources of infection, and it is even possible that later contact with the lochial 
discharges may originate the disorder. Andrews,^ Zweifel,^ and others, 
however, have failed by inoculation of healthy lochia to produce the disease. 

Opinions differ in regard to the exact time of the inoculation, which 
probably is more likely to occur in retarded labors and with face-presenta- 
tions. Mules {loG. cit.) thinks the pus may be introduced into the eyes by 
the edge of the perineum, the anterior edge of which becomes an elastic 
curved cord, which, after slipping over the forehead, presses for a shorter 
or longer time on the eyelids, depositing thus vaginal secretion within them. 



^ Klin. Monatsbl. f. Augenheilkunde, Julj^, 1887. 

■'' Die Ursachen und die Verhiitung der Blindheit, p. 113. 

» Medical Chronicle, 1888. 

* Hygeia, 1884, p. 404. 

5 Medical Eecord, July 24, 1886. 

6 ISTew York Medical Journal, October 25, 1885. 
^ Archiv f. Gynakol., xxii. 329. 



LACHRYMAL APPARATUS, COXJUXCTIVA, AXD CORNEA. 79 

Boys are more frequently attacked than girls. Emmert/ of Bern, 
has demonstrated a relation between the temperature and this disease. In 
cold climates ophthalmia neonatorum is esj)ecially frequent iu the summer 
mouths ; iu hot countries, in the spring and autumn. 

Pathology and Pathological Anatomy. — Horner examined an eye 
which for forty-eight hours had been the subject of ophthalmia neonatorum, 
and found that the oedematous swelling limited a general laminated struc- 
ture of the tarsal conjunctiva. The epithelium of the bulb was tolerably 
preserved ; the superficial layer of that covering the tarsus was curled, 
irregular, and wanting ; the swollen vessels were exposed and hemorrhages 
present ; the papillse were swollen, and there was much lymphoid infil- 
tration. 

The gonococci are seen in the nuclei and at the margin of the epithelial 
cells and on the surfaces of and within the pus-cells ; later they penetrate 
the epithelium and enter the lymph-spaces. The infectious secretion intro- 
duced into an eye will produce purulent ophthalmia, so the pus from it can 
be in turn inoculated into the urethra with the production of a purulent 
inflammation. 

Symptoms. — Ophthalmia neonatorum usually begins on the third day 
after birth, but may set in as early as from twelve to forty-eight hours after 
inoculation, or be delayed, when it is the result of a secondary infection 
from soiled fingers or sponges or cloths, to a much later date. Almost 
always both eyes suffer, the one being earlier and frequently more decidedly 
aifected than its fellow. Four stages of the disease are common, but, as 
these vary in different cases and more or less rapidly shade the one into the 
other, no very sharp lines need be draw^n. A slight redness of the conjunc- 
tiva, with a trifling discharge in the corner of the eye, is rapidly succeeded 
by great cushion-like swelling of the lids, wuth intense chemosis and con- 
gestion of the conjunctiva, accompanied by severe pain and discharge; the 
surface of the swollen lid is hot, dusky red, and tense ; the upper lid over- 
hangs the lower, and at first can only with difficulty be everted. The 
discharge, which in the beginning is slightly turbid, soon changes to a 
yellow or greenish -yellow pus, and is secreted in great quantities. If the 
lids are everted during the first day or two of the disease, the conjunctiva 
wall be found to be swollen, red, and velvety, and that upon the eyeball 
intensely injected ; upon the surface easily-detached flakes of lymph are 
found ; later the conjunctiva becomes rougher, of a dark-red color, spots of 
ecchymosis appear, or it is succulent and easily bleeds. Marked chemosis 
and infiltration of the ocular conjunctiva succeed, forming a hard rim ; 
at the bottom of the crater-like pit thus produced, the cornea may be seen ; 
the thick cream-like discharge increases, and either flows out from beneath 
the overhanging upper lid on to the cheek, or is packed up in the conjunc- 
tival cul-de-sac. 

1 Annales d'Oculistique, 1881, p. 63. 



80 AFFECTIONS OF THE EYELIDS, 

The lids now may lose much of their tense character, and can be more 
easily everted ; the conjunctiva is puckered into folds and papilla-like 
elevations, and the discharge contains an admixture of blood and serum. 

Fig 7 





Ophthalmia neonatorum. (Philadelphia Hospital.) 

Gradually the disease declines, and in from six to eight weeks the discharge 
ceases. The relaxed palpebral conjunctiva is thick and granular, looking 
like the granulation-tissue which surrounds wounds. The ocular conjunc- 
tiva is also thickened, and positive cicatricial changes may remain. 

The chief danger is destruction of the vitality of the cornea, the danger 
of which is materially increased if this membrane becomes lustreless, dull, 
and hazy within the first day or two of the disease. Frequently small, 
oval ulcers form near the limbus, either transparent or surrounded by an 
area of cloudy infiltration. In many mild cases the cornea escapes without 
harm. The changes which take place in the cornea are due in part to 
strangulation of the vessels by the swollen tissue, but largely to direct 
infection of its substance by the presence of the discharge. 

In the formation of a corneal ulcer, either its healing with regeneration 
of the corneal tissue talves place, or else perforation occurs. The result of 
perforation will depend upon the amount and character of the destruction 
of the corneal tissue. When the ulcer is central and perforates, the aque- 
ous humor escapes, the lens is pressed forward against the posterior surface 
of the cornea, and the opening becomes closed with lymph. This renders 
the re-collection of the aqueous possible, or, when it occurs, returns the lens 
to its proper position, leaving upon its anterior capsule a little mass of 
lymph, and the formation of a pyramidal cataract results. 

Perforation of an ulcer peripherally situated, especially below, is fol- 
lowed by adhesion of the iris to the opening. The aqueous escapes, and, as 
the iris and the lens fall forward, the former becomes entangled in the per- 
foration and is fixed by inflammatory exudation. The adhesion is either 
on the posterior surface or in the cicatrix, and the resulting dense white 
scar receives the name adherent leucoma. If the resriou of the scar is 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 



81 




bulged forward because it is uuable to resist the intraocular tension and 
jDressure, antenor staphyloma results. The effect of extensive necrosis and 
sloughing of the corneal tissue with total prolapse of the iris, matting to- 
gether of the parts by exudation and protrusion of the cicatrix, is the 
formation of a total anterior staphyloma. In rare instances an adhesion 
between an ulcerated spot upon the cornea and the surface of the tarsal 
conjunctiva takes place, resulting in the production of a symblepharou, 
even in the absence of any diphtheritic processes in the ulceration. Hutch- 
inson ^ has seen in a child of five 
years double ptosis which had fol- 
lowed an attack of purulent oph- 
thalmia in infancy. 

Finally, perforation may be 
followed by inflammatory involve- 
ment of the ciliary body and cho- 
roid, and the rapid destruction of 
the eye through panophthalmitis, 
or a slower shrinking of the tissue 
with atrophy of the bulb. Dense 
opacity occasionally appears in the 
cornea during convalescence, and 
may go on to softening and ulcer- 
ation, or clear up perfectly. It may arise with great suddenness, and, when 
it occurs in the lower half of the cornea, a deep indentation, owing to the 
pressure of the margin of the lid, is likely to occur. 

Ophthalmia neonatorum does not always follow the course just described. 
In many instances the inflammation is mild, and the secretion and general 
ajipearance of the eye are not far diflereut from those of an ordinary case 
of catarrhal or muco-purulent ophthalmia. In these instances the cornea 
escapes injury. 

The appearance of the conjunctiva materially differs in difl^erent cases. 
Its surface may be covered over, not merely with easily-detached flakes of 
lymph, but with a positive, gray, false membrane, and even, more rarely, 
with a deep infiltration like that seen in diphtheritic conjunctivitis. Con- 
stitutional disturbance is not lacking, with restlessness, fever, and distinct 
depression. Lucas ^ has seen an eighteen-months-old baby suffering from 
ophthalmia neonatorum have at the same time synovitis of the knee and 
wrists of the same character as such complications during gonorrhoea. 
Analogous cases have been reported by Sasworuitzky,^ Debierre,* and Darier.^ 

Diagnosis. — The onset and character of the disease, its symptoms and 



Symblepharon of upper lid following purulent 
ophthalmia. (Philadelphia Hospital.) 



1 Ophthalmological Hospital Keports, vii. 43. 

2 British Medical Journal, 1885, ii. 57, 699. 

^ Abstract in Archives of Ophthalmology, vol. xv. 
* Kevue Generale d'Ophtalmologie, 1885, iv. 299. 
5 Archives d'Ophtalmologie, Mars-Avril, 1889. 



Vol. IV.— 6 



82 AFFECTIO^'S OF THE EYELIDS. 

course, render any mistake in regard to its nature practically impossible. 
The only word of caution necessary is to avoid any iudiiference in regard 
to what at first may appear to be only a trivial inflammation in the eyes 
of a new-born child, remembering that with great rapidity a virulent and 
destructive inflammation may follow. 

Prognosis. — This is always grave, the gravity increasing in direct 
proportion to the violence of the inflammation and the condition of the 
cornea. Under the newer methods of treatment, more eyes are saved 
than was formerly the case, and still more would escape were it possible 
to impress upon the attendants of children thus afflicted the necessity of 
seeking capable medical advice at the very moment of the appearance of 
any trouble. If, as only too frequently is the case, treatment has been 
neglected until extensive sloughing of the cornea has occurred, no form of 
medication can do more than relieve the violence of the inflammation, 
which, when it subsides, leaves the child Avith sight hopelessly marred, 
perhaps destroyed. 

Prophylaxis. — One of the most fruitful causes of blindness is this 
form of inflammation of the eyes of new-born infants. Thirty per cent, 
of the inmates of institutions in the United Kingdom have lost their sight 
from this cause. According to Prof. Magnus, of Breslau, 71.99 per cent, 
of all who become blind during the first year of life are rendered so by 
purulent ophthalmia ; even of those who become blind before the twentieth 
year of life it constitutes 23.5 per cent. ; in other words, of every' ten 
thousand children under five years of age, 4.28 per cent, lose their vision 
by ophthalmia neonatorum. In the blind asylums of Switzerland the pro- 
portion is 26 per cent. ; in those of Austria, Hungary, and Italy, about 
20 per cent. ; while in Spain and Belgium it falls to about 11 or 12 per 
cent.^ In the face of these facts, and with the knowledge, as Howe's 
statistics show, that, owing to the carelessness of the emigrant population of 
this country, blindness is on the increase, the prophylaxis and treatment of 
this affection are of the highest importance. Crede's method of treating the 
eyes of the new-born child is the one which is followed by the best results. 
This consists in dropping into the conjunctival sac one drop of a two-per- 
cent, solution of nitrate of silver, the lids having been wiped dry. Occa- 
sionally decided reaction has followed this application, requiring the use of 
cold to allay the irritation, and Pomeroy^ has related a case in Avhich severe 
hemorrhage followed the use of nitrate of silver in an eye already inflamed. 
This method reduced the percentage of the disorder in Crede's service from 
7.8 to 0.31. Other methods, like that first employed by Bischofl", in Basel, 
of washing out the vagina before birth with, injections of carbolic acid, 
and the eyes of the newly-born with salicylic acid, or the later Kaltenbach 
method of washing the vagina with a 0.4-per-cent. bichloride solution after 

1 See Lancet, July 20, 1889. 

2 New York Medical Eecord, August 20, 1887. 



LACHRYMAL APPAEATUS, COXJUXCTIVA, AND CORXEA. 83 

each examination, and cleansing the eyes with distilled water, have not com- 
pared favorably with Crede's procedure. L. Korn ^ has concluded, after a 
careful examination of this matter, that Crede's plan is absolutely safe and 
certain, although painstaking cleanliness during the birth and also in child- 
bed may reduce the possibility of this disease to a minimum. Mules {loc. 
cit.) quotes from Fuchs the following statistics, which are interesting in this 
connection.^ 

Number of Ophthalmia 

Children. Xeonatorlm. 

No treatment 1092 19.26 

One-per-cent. carbolic acid 1541 7.42 

Crede'.? method 1250 5.44 

Of not less importance is the necessity of searching for sources of in- 
fection in the hands of the mother and the child. Xot only should all anti- 
septic precautions be taken during the labor and immediately afterwards, 
but, if infection is known to exist, the child should be removed from the 
immediate surroundings of the lying-in woman and the possibility of 
contamination by utensils and towels. 

Treatment. — Naturally, this deals with three conditions, — the inflam- 
matory swelling of the lids, the state of the conjunctiva, and the corneal 
complications. 

1. During the earlier stages, when the lids are tense and the secretion 
lacking in its later creamy character, in addition to absolute cleanliness, 
local application of cold is the most useful agent. Kries ^ has shown that 
the coccus develops only slowly at a temperature of 90° to 92° F., and 
Weeks (Joe. cit.) has demonstrated that the temperature of the conjunctiva 
may be reduced to 88° or 94° according to the amount of swelling of the 
lids. The cold should be applied in the following manner : upon a block 
of ice square compresses of patent lint are laid, which, in turn, are placed 
upon the swollen lids and as frequently changed as may be needful to 
keep up a uniform cold impression. This is far preferable to the use of 
small bladders containing crushed ice ; indeed, the use of ice for infants is 
not advisable. The length of time occupied with these cold ai>j:)lications 
must vary according to the severity of the case. Sometimes they may be 
almost continuously used, and sometimes frequently for periods of half an 
hour at a time. On the other hand, hot fomentations are occasionally better 
than cold, especially when the corneal complications exist. These are em- 
ployed in like manner with squares of antiseptic gauze wrung out in 
carbolized water of a temperature of 120° F. and frequently changed. 

2, Constant removal of the discharge must be assiduously practised. 
The lids are to be gently separated, the tenacious secretion wiped away 

1 Archiv f. Gynakol., 1888, xxxi. 2, S. 240. 

2 For further statistics in regard to the comparati%'e value of various forms of prevent- 
ive treatment, see Peuch, Archives de Tocologie, des Maladies des Femmes et des Enfants 
nouveau-nes, Fevrier, 1890. 

3 Wien. Med. Wochenschr., 1885, Nos. 30, 31, 32. 



84 AFFECTIONS OF THE EYELIDS, 

with bits of moistened lint or absorbent cotton, and the conjunctival sac 
freely irrigated with an antiseptic solution. For this purpose a saturated 
solution of boracic acid, or one of corrosive sublimate, a grain to the pint, 
inasmuch as a solution of one to ten-thousand will materially retard the 
vitality of the coccus, may be employed. Special and ingenious forms of 
lid-irrigators have been devised by Story and others for this purpose. The 
cleansing process must be repeated at least every hour, day and night, but, 
if necessary, should be much more frequently used. Many solutions other 
than those mentioned have found favor with surgeons ; for instance, alum 
(gr. viii-f gi), sulphate of zinc (gr. ii-f gi), carbolic acid in one-half- to five- 
per-cent. solution, weak solutions of nitrate of silver, solutions of quinine, 
as recommended by Tweedy, alcohol and bichloride-of-mercury solution, 
advocated by P. H. Mules,^ iodoform ointment of four-per-cent. strength, 
creolin in one-per-cent. solution, and cocaine, either dropped frequently upon 
the conjunctiva or introduced in the form of a salve. 

3. The local application of nitrate of silver to the conjunctiva must not 
be employed in the earlier stages before free discharge is established, nor in 
those cases, no matter what the stage, where the lids are tense and board-like 
and the surface of the conjunctiva is covered with a gray film or a positive 
false membrane. When the secretion is free and creamy, when the lids 
are relaxed, when the conjunctiva is dark-red and puckered into papilla- 
like excrescences, the time for its application has come. Once a day the 
conjunctiva should be brushed over with a solution, ten or twenty grains 
to the ounce, its surface first having been carefully freed from any adhe- 
rent discharge, and all excess washed away with water. In severe cases 
the mitigated stick and even the solid pencil of nitrate of silver may be 
employed, great care being taken to neutralize the excess with a solution 
of common salt. All strong applications must be made by the hand of the 
surgeon himself. Ulceration of the cornea does not alter the treatment de- 
scribed, except that all pressure upon the globe while manipulating the eye 
is to be avoided. So long as the discharge is abundant the use of the caustic 
is indicated. 

At the first appearance of corneal haze a solution of atropine is to be 
dropped two or three times daily into the eye. If, however, a marginal 
ulcer forms and danger of perforation is imminent, or even if this has oc- 
curred, good results will follow the use of a solution of sulphate of eserine. 
When the vitality of the cornea is threatened or the surface of the conjunc- 
tiva is covered with a gray film, better results follow the use of hot applica- 
tions instead of cold, and I have more than once seen cases apparently very 
hopeless go on to recovery under the use of scrupulous antiseptic cleansing 
and the almost continuous application of hot compresses. Persistent swell- 
ing of the conjunctiva is sometimes treated by scarification. Division of 
the outer commissure to relieve pressure, leeching, and indeed any form of 

1 British Medical Journal, February' 4, 1888. 



LACHEYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 85 

treatment followed by decided loss of blood, are hardly applicable to young 
infants, although they may be indicated in adults. 

If one eye alone is aifected, suitable protection for the sound eye should 
be provided. This may be accomplished by antiseptic bandaging of the 
uninflaraed organ (Buller's shield is difficult of application in infants). 
Fraenkel ^ has suggested the daily use in the unaffected eye of a drop of a 
two-per-cent. solution of lunar caustic. 

On the whole, that treatment which has in view reduction of the inflam- 
mation with cold applications, for which under the conditions named hot 
affusions are substituted, absolute cleanliness, frequent irrigation with anti- 
septic solutions, and at the proper stage nitrate of silver, will meet with the 
best success. The attendants must be impressed with the fact that upon 
their faithful carrying out of directions and upon their unremitting care 
much, if not all, of the hope of bringing the case to a successful termination 
depends. The attendants must further be impressed with the contagious 
nature of the pus : all bits of rag and pledgets of lint used in the treatment 
must be destroyed, and after each treatment the hands of those engaged must 
be thoroughly washed and then disinfected with a solution of bichloride of 

mercury. 

MUCO-PURULENT OPHTHALMIA. 

Synonymes. — Catarrhal ophthalmia or conjunctivitis. 

Definition. — This is an inflammatory disease of the conjunctiva char- 
acterized by congestion, dread of light, spasm of the lids, and free muco- 
purulent discharge. 

Etiology. — The disorder is commonest in warm and changeable weather ; 
it is markedly contagious, and will pass rapidly from one member to an- 
other of a household, varying much in severity with each. In the severe 
forms micro-organisms are found, which may be the cause of the contagion. 
Very troublesome ophthalmia follows or accompanies the exanthemata (ex~ 
anthematous ophthalmia), especially measles and scarlet fever ; scrofulous 
and anaemic children are most liable ; neglected hypersemias and the pres- 
ence of follicular granulations increase the susceptibility to infection. 

Symptoms. — There is at first redness of the edges of the lids, with in- 
creased vascularity of the conjunctiva and gritty sensation in the eye, some 
pain, and a free discharge, which glues together the edges of the lids, which 
are slightly swollen. Usually the cornea does not suffer, but in young chil- 
dren, especially those who have had measles, superficial ulcers form ; the 
photophobia then becomes intense. The disease varies in type from a 
mere hypersemia to a severity of such degree that it is not readily distin- 
guished from purulent ophthalmia, into which type it may pass by neglect. 

There is a large group of cases of acute conjunctivitis (simple or catar- 
rhal conjunctivitis) which does not conform to the above description ; those, 
for example, where there is more or less redness, little or only slight dis- 

1 Klin. Monatsbl. f. Augenheilkunde, February, 1889. 



86 AFFECTIOXS OF THE EYELIDS, 

charge, and where local irritants like wind and dust or the strain occasioned 
by neglected ametropia are evidently the causes of its existence, — cases, in 
short, which correspond to hypersemia of the conjunctiva. 

In other varieties exposure and even rheumatism seem to be the causes : 
and among other factors catarrh of the nose and of the bronchia and eczema 
deserve mention. 

In that form of conjunctivitis which is seen especially in the spring and 
fall, and to which the meaningless name "pink ey^' has been applied, Weeks^ 
has described and isolated a special bacillus which he considers the cause of 
the trouble ; and, according to E. Schmidt,^ epidemic conjunctival catarrh is 
due to a coccus identical with the staphylococcus pyogenes albus. 

Children frequently suffer with marked muco-purulent ophthalmia coin- 
cidently with the appearance upon the face of the vesico-pustules of impetigo 
contagiosa. Muco-purulent ophthalmia of any type becomes a grave dis- 
order if it breaks out in schools, homes, or any institution where numbers 
of children are gathered together. It is a markedly infectious disease, and 
is almost certain to run through the establishment ; the importance of the 
trouble is rendered all the greater if granular lids are present.^ 

Diagnosis. — The diagnosis presents no difficulty. Inspection will reveal 
the characteristic congested, opaque, and velvety appearance of the conjunc- 
tiva, and the presence or absence of epithelial ulcers or phlyctenulse, while the 
mobility of the iris and the preservation of its normal color and the charac- 
ter of the coarse bulbar injection (not fine and pericorneal) exclude iritis. 

Prognosis. — This is good, but the cases following measles are some- 
times very intractable. So, also, when the ophthalmia has existed for a 
long time, and if neglected, the papillse of the palpebral conjunctiva be- 
come hypertrophied, and loops of vessels upon the ocular conjunctiva lie 
so closely together that an almost uniform red surface is the result, forming 
one type of chronic ophthalmia. 

Knapp ■* saw pterygium super ius as a sequel of an attack of purulent 
ophthalmia in a girl aged eleven years, an inmate of a home in which the 
disorder was epidemic. 

Treatment. — The eye should be frequently and thoroughly cleansed 
with a weak solution of bichloride of mercury (one grain to the pint) or a 
solution of boracic acid (fifteen grains to the ounce). The lids may be 
everted and the surfaces brushed over with nitrate of silver (five grains to 
the ounce, or stronger if the discharge is copious). In the later stages, 

.1 Medical Eecord, May 21, 1887. 
2 Inaugural Dissertation, St. Petersburg, quoted in Medical Chronicle, June, 1888. 

* In the event of an epidemic of purulent or muco-purulent ophthalmia in a school, 
workhouse, or similar institution, scrupulous attention to isolation of the affected inmates, 
strict cleanliness, and especially the use of separate utensils, towels, etc., are necessary. 
Touching the proper regulations under such circumstances, the reader is referred to a paper 
on " The Ophthalmic Isolation School at Hanwell," by Sydney Stephenson, Lancet, April 
5, 1890. 

* Archives of Ophthalmology and Otology, ii. 54. 



LACHRYMAL APPARATUS, COXJUXCTIVA, AND CORXEA. 87 

when the discharge is scanty, the nitrate of silver may be discontinued, and 
some other astringent collyrium substituted ; zinc and ahim answer very 
well. Dusting in calomel or iodoform or subnitrate of bismuth acts very- 
well occasionally in stubborn cases. Photophobia calls for dark glasses 
or a large shade, but the eyes must not be bandaged. The pernicious habit 
of using poultices, tea-leaves, scraped potatoes, and the like cannot be con- 
demned too strongly. Atropine drops, provided they cause no irritation, 
are useful if phlyctenulae complicate the trouble. 

Good diet, fresh air and exercise, iron, if there is ansemia, quinine, 
especially if the patients come from damp and possibly malarious quarters, 
and cod-liver oil, if scrofula is present, are all indicated. 

FOLLICULAK OPHTHALMIA. 

Synonymes. — Follicular conjunctivitis (Saemisch), Conjunctivitis fol- 
licularis simplex (Raehlmann), Trachoma folliculare (Mandelstamm). 

Definition. — This is an aifectionof the conjunctiva characterized by the 
presence of small pinkish prominences in the conjunctiva, for the most part 
in the retro-tarsal folds, and usually arranged in parallel rows. 

Etiology. — The disease arises under the influence of bad hygienic sur- 
roundings, and is especially engendered in pauper schools, asylums, and 
prisons, under which circumstances it may appear as an aggravated epi- 
demic ; but it is frequently seen in mild form among children generally. 
Much difference of opinion exists as to whether follicular conjunctivitis 
should be placed in a separate category from granular disease, as has been 
done by Saemisch,^ Swanzy,^ Meyer,^ and other authors, or should be looked 
upon as an early stage of granular ophthalmia, as is taught by Xettle- 
ship ^ and other writers. Reich ^ looks upon this affection as a mild form 
and an early stage of trachoma, into the severe types of which it frequently 
passes, and Stilling® in endemic follicular ophthalmia has observed the 
disorder in school-children pass into the condition of granular lids. Bacte- 
riologically, Kucharsky "^ considers trachoma and follicular disease identical. 
Admitting the not infrequent apparent transitional forms, the evidence, 
clinically at least, that this is a very distinct disease, widely different from 
granular ophthalmia, warrants a separate description. 

Symptoms. — The children (for it mostly occurs in children and young 
people) complain of slight dread of light and inability to continue at close 
work, and inspection reveals numerous round elevations in the conjunctiva, 
chiefly along the fornix, which are tumefied lymphatic follicles. Their color 

i 

^ Graefe u. Saemisch, Handbuch der gesammten Augenheilkunde. 

^ Hand-Book of Diseases of the Eye, 2d edition. 

3 Diseases of the Eye, translated by F. Fergus, 1\I.B. 

* Ibid., 2d edition. 

^ Wratsch, No. 7, Abst. in Archives of Ophthalmology, December, 1888. 

6 Berlin. Klin. Wochenschrift, No. 22, 1888. 

f Centralblatt f prakt. Augenheilkunde, September, 1887. 



88 AFFECTIONS OF THE EYELIDS, 

varies from nearly white to a decided pink. They are usually unassociated 
with decided symptoms of catarrhal conjunctivitis, and the bulbar conjunc- 
tiva is not greatly reddened, although they sometimes give rise to ulceration 
of the margin of the cornea, decided hypersemia, and swelling of the con- 
junctiva. Uncorrected ametropia aggravates the disorder. After the dis- 
appearance of the enlarged follicles the conjunctiva remains in its natural 
state. 

Diagnosis. — This disorder is to be distinguished from granular lids by 
observing that the small bodies are neither so prominent nor so highly 
colored as hypertrophied papillae, that the mucous membrane is not affected 
more deeply than the lymphatic follicles, and that cicatricial changes are 
not present. 

The prognosis is good, in so far that the disease will disappear and leave 
the mucous membrane in a smooth condition ; but the affection is trouble- 
some, in that it lasts for months, and under indifferent hygienic surround- 
ings, especially in crowded asylums, is likely to prove a stubborn endemic. 

Treatment. — The patient should be put in the best possible healthful 
surroundings, and given good food, iron, and quinine. Locally, boric acid, 
weak bichloride solutions, and occasional dusting in of iodoform and sub- 
nitrate of bismuth and calomel, equal parts, are the best measures. A salve 
of one-half grain of sulphate of copper to the drachm of vaseline has been 
highly extolled. If refraction-error exists, appropriate glasses should be 
ordered. Vossius ^ urges the necessity, especially if the disease is endemic 
in asylums, of excising the affected areas. Galezowski and Schneller have 
practised similar procedures. 

GKANULAR OPHTHALMIA. 

Synonymes. — Granular conjunctivitis, Egyptian ophthalmia, Tra- 
choma. 

Definition. — This is an inflammation of the conjunctiva in which this 
membrane loses its smooth surface, owing to the formation of rounded 
granulations, which, after absorption, leave cicatricial changes : it may 
be studied conveniently under two forms, — acute granulations and chronic 
granulations. 

Etiolog-y. — Acute granulations may arise primarily under the influence 
of bad hygienic surroundings, and appear eudemically in institutions where 
the inmates are crowded together. The disease is contagious by the contact 
of the secretion from one eye with another, and also probably through the 
atmosphere. The chronic form may result from the imperfect disappear- 
ance of the acute granulations, but much more frequently appears as a 
primary disorder. Certain races are strongly predisposed to the affection, 
— the Irish, Jews, and Eastern races ; children are attacked less commonly 

1 Therapeutische Monatsheft, June and July, 1889. 



LACHRYMAL APPARATUS, COXJUXCTIVA, AND CORNEA. 89 

than adults. According to Burnett/ the negro race enjoys a comparative 
immunity from trachoma, and he believes the disease should be classed with 
the dyscrasias. Jackson^ has seen granular lids in a negro boy of ten 
years. The Indians are frequent sufferers from granular lids. Overcrowd- 
ing, bad ventilation, depressed health, are all factors in its production. 
Since the publication in 1881-82 of Sattler's work in which he attempted 
to prove that trachoma was due to the presence of a micrococcus, much 
work has been done in this line, bat we are not yet in a position to state 
definitely the relation of micro-organisms to this disease, nor has the 
trachoma-coccus been positively isolated. 

Pathology. — Two views have been prominently held in regard to the 
pathological anatomy of the " trachoma granules," — the one that they are 
derived from the natural lymphatic vesicles, the other that they are to be 
looked upon as new growths of special pathological character. The latter 
view is the one which in recent times has received the widest acceptance. 
The presence of the granulations provokes thickening and vascularization 
of the conjunctiva, the cellular elements change into connective tissue, and 
cicatricial alterations take place, so that in the advanced disease the sub- 
mucous tissue is involved, and finally fatty change in the tarsus arises. 
With the disappearance of each granulation in a cicatricial mass, shrinking 
of the conjunctiva takes place, resulting in contraction and atrophy, with 
hypertrophy and distortion of the lid. 

Symptoms. — Acute Granulations. — The lids are swollen, the conjunc- 
tiva reddened, the papillae hypertrophied, between which are found non- 
vascular roundish granulations. The dread of light is intense, the lids are 
spasmodically closed, and, on their forcible separation, scalding tears gush 
out. The bulbar conjunctiva is intensely injected, superficial vascularity 
of the cornea arises, and ulceration, especially of its margin, may appear. 
Severe eye-, temple-, and forehead-pain results. At first there is little dis- 
charge, but later a muco-purulent stage begins, and the process terminates 
either favorably by the absorption of the granulations, or unfavorably by 
running into a chronic form. 

Chronic Granulations. — Often without antecedent inflammation these 
appear, usually first on the lower lid, in the form of grayish-white semi- 
transparent bodies, which, accordingly as they resemble minute grains of 
boiled sago, or vesicles, have been called " sago-grain" or vesicular granu- 
lations. At first there is little discharge, perhaps only gluing together of 
the lids ; later, with fresh development of new granulations and thickening 
and hypertrophy of the papillae, the secretion becomes freer, and muco- 
purulent or purulent in character. Granular disease may at any stage take 
on an intense acute inflammatory reaction, with the production of a copious 
contagious discharge. 

1 Medical Kecord, March 24, 1888. 
^ Polyclinic, January, 1888. 



90 AFFECTIONS OF THE EYELIDS, 

Sequelae of Granular Lids. — The most important results of long- 
continued granular lids are trichiasis, distichiasis, and entropion, conditions 
already described (page 62), atrophy and shrinking of the conjunctiva from 
cicatricial changes (page 81), cloudiness of the cornea, and pannus. The 
latter is due to the formation of a vascular tissue beneath the epithelium 
of the cornea, and begins below the upper lid, but may in severe cases in- 
volve the entire membrane. The proper corneal tissue may be unaffected, 
or ulceration and softening may occur. Pannus is usually taught to be 
caused by the friction of the granulations ; but, according to Raehlmann, 
it is a special implantation of the trachoma-process upon the cornea, a 
view which receives some support from the observation of Hansen Grut 
that with the granulations of spring catarrh pannus never occurs (page 93). 

Diagnosis. — This presents no difficulties. Acute granulations must be 
distinguished from purulent ophthalmia, but the chronic form is made 
evident by the direct inspection of the everted lids. 

Prognosis. — Under the best circumstances, granular disease of the con- 
junctiva, when well established, is a tedious disease and greatly endangers 
the useful vision of the patient. Relapses are frequent, and the disorder 
at any time is likely to assume an intense inflammatory action. Its conta- 
gious character renders the affection especially dangerous in pauper schools 
or any institution where large numbers of inmates are gathered together. 
The muco-purulent discharge, even when present in slight degree, is likely 
to be conveyed from one subject to the other by the careless use of towels 
or common utensils. Great caution is necessary under such circumstances 
to prevent a disastrous epidemic. 

Treatment. — Acute Granulations. — These must be managed upon the 
principles which govern the treatment of acute ophthalmias generally, and 
in the inflammatory stage require soothing remedies rather than strong 
astringents and caustic applications. 

Chronic Granulations. — When the height of the inflammation has sub- 
sided, or in the chronic stage, the treatment is directed to the absorption of 
the granular condition of the lids. For this purpose numerous caustic and 
astringent applications have been recommended. For routine treatment 
probably no better ones exist than nitrate of silver (ten grains to the ounce) 
and a crystal of sulphate of copper. Tannin and glycerin in a strength of 
twenty grains to the ounce is an excellent application in the milder forms, 
or after an impression has been made with more decided remedies. Liquid 
carbolic acid is praised by E. Treacher Collins. Betanaphthol, iodoform, 
hydrastin, and an ointment of the yellow oxide of mercury are all worthy 
of trial. Very satisfactory results follow the use of strong solutions of 
bichloride of mercury, one to one hundred and twenty or one to three 
hundred, applied to the everted lids with a mop of absorbent cotton, the 
patient at the same time using a tepid collyrium of the same drug of the 
strength of a grain to the pint. 

More vigorous procedures are scarification of the conjunctiva, abscission 



LACHRYMAL APPARATUS, CONJUXCTIVA, AND CORNEA. 91 

of the granulations/ and squeezing them out between the thumb-nails, or 
with a speciallj-devised forceps as advocated by Hotz. Excision of the 
fornix eonjunctivse has been proposed and practised by some surgeons, and 
the operation of peritomy, or the excision of a ring of conjunctival tissue 
surrounding the corneal margin, is also advised. Any cases of stubborn 
pannus without ulceration of the cornea may be treated by the production 
of a violent conjunctivitis with a three-per-cent. infusion of jequirity applied 
twice a day to the everted lids, a method introduced by De Wecker to sub- 
stitute the old-fashioned inoculation of the conjunctiva with bleunorrhoeic 
pus. 

Much patience is required for the successful treatment of granular lids, 
together with frequent changing of the local applications, and care to dis- 
continue the severe caustics and apply sedative lotions with atropine to 
prevent iritis if high-grade inflammatory symptoms should set in. The 
patients usually require a tonic, and must be placed in the best possible 
hygienic surroundings. If at any time severe swelling of the lids comes 
on, with dangerous pressure upon the cornea, this should be relieved by the 
operation of cauthoplasty. 

Chronic Ophthalmia (chronic conjunctivitis), a common disease in 
elderly people, is more rarely seen in children, either as the sequel of acute 
conjunctivitis or of independent origin. There are hypersemia, thickening 
of the papillary layer of the tarsal conjunctiva, swelling of the caruncle, 
and soreness of the edges of the lids, especially at the outer canthus. If 
this results from a chronic blennorrhoea, the conjunctiva is thrown into 
velvety folds and involutions from one end of the lid to the other. Cleanli- 
ness, and the application of "• lapis divinus," the alum crystal, or painting 
with a strong solution of bichloride of mercury (one to five hundred), are 
the best local measures. 

Toxic Conjunctivitis is a name applied to that form of inflammation 
of the conjunctiva caused by the prolonged use of certain drugs, prominent 
among which are atropine and eserine. The disease usually appears in 
the form of follicular granulations, sometimes associated with considerable 
swelling of the lids and an eczematous appearance of the surrounding tissue. 
Conjunctivitis produced by the prolonged use of cocaine has been described 
by Kipp ^ and Mitteudorf,^ and W. C. Ayers * reports granulations from 
the same cause. These cases occurred in adults. 

Lymphangiectasis of the Conjunctiva consists in the appearance 
of small blisters in the conjunctiva filled with semi-transparent fluid and 
usually gathered together in masses. They are situated superficially, and 
readily move with the conjunctiva over the subjacent tissue. The explana- 

1 See, especially, observations of Vossius, loc. cit. 

2 Medical Kecord, October 6, 1888. 

. » New York Medical Journal, October 6, 1888. 
* Archives of Ophthalmology, September, 1888. 



92 APFECTIOXS OF THE EYELIDS, 

tion of their appearance is the probable interference of the natural lymph- 
flow, and the consequent distention of the lymph-spaces. According to 
Berry/ this affection is most frequently met with in children, and, as it 
disappears spontaneously, it requires no treatment. 

CONJUNCTIVITIS ^STIVALIS. 

Synonymes, — Friihjahrscatarrh (Saemisch), Phlyctsena pallida 
(Hirschberg), Hypertrophic peric^ratique de la conjonctive (Desmarres), 
Hypertrophia epithelialis sestiva (Emmert), Spring catarrh. 

Definition. — This is a form of conjunctival disease usually seen in 
children, and characterized by photophobia, stinging pain, considerable 
mucous secretion, and an hypertrophy of the tissue surrounding the limbus 
of the cornea. 

Etiology. — The present state of our knowledge does not yield definite 
information in regard to the cause of this peculiar disease. The character- 
istic behavior of the disorder is its return with the early spring, about 
April, and its subsidence in the fall and winter ; although Hansen Grut ^ 
doubts if the spring and summer exacerbations are the most marked fea- 
tures, and points out how phlyctenular conjunctivitis flourishes in the 
summer. It is seen most frequently between the ages of five and fourteen 
years, usually in boys, although Burnett^ says the largest contingent of 
cases comes from the female sex. Emmert^ has observed a case in an 
individual aged fifty-one, and Saemisch another in a child of three. In 
Emmert's collection of twenty-nine cases seen during ten years, the greatest 
number occurred in June, then in May, July, and August ; single cases oc- 
curred in all the other months except February, March, and April, when 
none appeared. I have seen one case w^hich began in the child's fifth year, 
and has reappeared each spring for four years, until last year, when it 
began in February. It may be accompanied with the disorder known as 
hay fever. Some writers, like Adolph Bronner,^ decline to consider vernal 
conjunctivitis as a distinct disease, but look upon it as a hypertrophic form 
of chronic conjunctivitis. 

Pathological Anatomy. — Anatomically, spring catarrh is a chronic 
epithelial overgrowth, with simultaneous hypertrophy of the connective 
tissue, the deeper layers of the conjunctiva remaining tolerably normal. 
An analogy between it and psoriasis has been pointed out. 

Symptoms. — The aifection begins like an ordinary conjunctivitis, and 
is always bilateral. There are photophobia and more or less mucous se- 
cretion, with circumscribed pericorneal injection and the formation in this 

^ Diseases of the Eye, Edinburgh and London, 1889. 

2 Nordisk Ophthalmologisk Tidsskrift, No. 1 ; American Journal of the Medical 
Sciences, September, 1888. 

^ Archives of Ophthalmology, x. 416. 
* Centralblatt f. prakt. Augenheilkunde, March, 1888. 
^ Lancet, July 14, 



LACHEYMAL APPAEATUS, CONJUNCTIVA, AND COENEA. 93 

region of small, gray, semi-transparent nodules, which swell up and overlap 
the cornea, which is usually unaffected, although its limbus may become 
thickened and corneal opacity result. The disease is most strikingly ob- 
served in the bulbar conjunctiva, but three varieties are described, — the 
limbus, palpebral, and mixed forms. The conjunctiva of the bulb is in- 
jected, and from the outer and the inner commissure superficial vessels run 
and empty into the swelling at the limbus. The conjunctiva palpebrarum is 
slightly thickened, and of a pale, dull color, as if brushed over with a thin 
layer of milk (Horner). In severe cases the tarsal conjunctiva is covered 
with flattened granulations with deep furrows between ; the lids droop and 
give the eyes a sleepy look. A peculiarity of this disease in the negro, as 
pointed out by Burnett {loe. cit), is the brownish pigmentation of the 
scleral base of the hypertrophied masses. 

Diagnosis. — The disease is to be distinguished from trachoma by the 
flattened appearance of the granulations, and the absence of infiltration and 
of pannus, a fact which tends to prove that the pannus of granular lids is 
not of mechanical origin. The peculiarity of the disease and its tendency 
to return with the early spring and subside in the fall and winter are further 
points to aid in a diagnosis. 

Prognosis. — The prognosis of the disorder is not unfavorable, except 
in so far as the recurrence is concerned. The cornea is not usually affected, 
although a slight opacity of the border may occur. Its course is a long 
one, and may last from eight to ten years. 

Treatment. — This appears to be efficacious only in so far as relief of 
the symptoms is concerned, and not in preventing the recurrence. The eyes 
may be protected with dark glasses, — a procedure, however, deprecated by 
Horner. Locally, the use of a mild astringent lotion and dusting in calo- 
mel are recommended. Dr. L. Webster Fox, of this city, informs me that 
he has obtained good results with the use of boro-glyceride. Hansen Grut 
employs the actual cautery to destroy the granulations. Internally, Fowler's 
solution should be exhibited. 

PHLYCTBNULAE OPHTHALMIA.^ 

Synonymes. — Phlyctenular conjunctivitis. Scrofulous ophthalmia. Ec- 
zema of the conjunctiva. 

Definition. — This is a form of inflammation of the conjunctiva charac- 
terized by the appearance of one or more white- topped vesicles situated 
chiefly upon the bulbar portion. 

Etiology. — The disease is believed to be of constitutional origin, and 
has for its subjects strumous and badly-nourished children. Errors of diet, 
the over-indulgence in pastries and unwholesome foods, the use of tea 
and coffee, often act as predisposing causes. It frequently follows in the 

1 This disease is so closely allied to phlyctenular keratitis that further discussion of it 
will be found under Diseases of the Cornea. 



94 



AFFECTIONS OF THE EYELIDS, 




Phlyctenular ophthalmia. (Children's Hospital. 



wake of the exanthemata, especially measles. Micro-organisms have been 
described ; Giiford ^ found seven varieties of micrococci, three of which 
seemed to bear some causal relation to this disease ; and E. Schmidt (Joe. 
dt) has described five varieties of microbes in connection with phlyctenular 
conjunctivitis, but inoculations with them were negative. 

Symptoms. — The pimples or phlyctenulse often lie near the corneal 
margin. They are usually from one to three millimetres in diameter. At 
first clear, the summit soon becomes turbid and may break down. The 

disease may exist in a single or 
Fig. 9. a multiple form ; usually each 

phlyctenula is supplied by a 
leash of dilated vessels. 

Sometimes the vesicles are 
large and yellow, and the disease 
receives the name jmstular oph- 
fhalmia. Under any circum- 
stances, it is accompanied by 
pain, dread of light, and in- 
creased lachrymation. It is not 
infrequently associated with 
muco-purulent ophthalmia, es- 
pecially when one or other of 
the exanthemata has preceded its appearance. In a multiple form numer- 
ous minute phlyctenulse are scattered over the conjunctiva, and are accom- 
panied by decided red injection, irritation, and photophobia. When the 
phlyctenulse border on the cornea, they frequently invade its substance and 
form the so-called phlyctenular ulcers, and larger ones are often the starting- 
point of severe marginal corneal ulceration (see page 104). The disease 
ordinarily runs a mild course, but tends to recur, just as do the relapsing 
corneal ulcers. The phlyctenulse generally break down and disappear in 
ten days or two weeks. 

Diagnosis. — Direct inspection will reveal the characteristic lesions of 
the disorder. 

Prognosis. — This is perfectly good under proper treatment, but neg- 
lected cases or such as have been treated by injudicious applications may 
become the starting-point of severe inflammations. 

Treatment. — Locally, the mild antiseptic washes previously described 
are to be employed, the most generally applicable being a lotion of boric 
acid. Much irritation calls for the use of atropine drops and the occasional 
instillation of cocaine. The eyes may be protected with colored glasses. 
Most important is attention to the condition of the alimentary canal. 
An excellent regulation treatment is a mild course of mercurial laxa- 
tives. Simple nourishing diet, good air, exercise, and internally quinine, 



^ Archives of Ophthalmology, xv. 180. 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 95 

iron, arsenic, and, in cold weather, cod-liver oil, complete the therapeutic 
measures. 

CEOUPOUS OPHTHALMIA. 

Synonymes. — Membranous or croupous conjunctivitis. Croup of the 
conjunctiva. 

Definition. — This is an inflammation of the conjunctiva characterized 
by a soft, usually painless, swelling of the lids, a membranous exudation 
upon the surface of the conjunctiva, and a scanty sero-purulent discharge. 

Etiology. — No distinct cause is known ; some relation exists between 
the disorder, scrofula, and eczema, and a definite age of childhood. The 
affected jmtients may at the same time be suffering from a similar condition 
of the respiratory tract (Knapp). The contagiousness of the disease has not 
been proved. In forty-five per cent, of the cases collected by Arnold Lotz,^ 
one eye only was affected. According to Horner {loc. dt), between birth 
and four years, among eight thousand cases of eye-disease, only one pure 
instance was seen. The rarity of the affection is further shown in that 
eighty-two cases only were seen during twenty years of the Basel Clinic. 
It is never found among the new-born, and never among grown-up people. 
In Lotz's analysis, two of the eighty-two cases were under one-half year, 
seventy-four per cent, between one-half year and three years, and very 
few among older subjects. 

Pathology. — This consists in the formation of a pseudo-membranous 
deposit of fibrinous character interspersed with lymphoid cells, which is de- 
posited upon the conjunctiva and does not infiltrate the deeper tissues. The 
formation of the membrane is like that seen in tracheal croup ; with this 
there is a proliferation of the papillary body of the conjunctiva. 

Symptoms. — These usually begin with an acute ophthalmia, succeeded 
by swelling of the lids, which, however, remain soft and pliant and usually 
not painful to the touch. In a few days the deposit of a characteristic false 
membrane takes place. This membrane, composed of coagulated fibrin, is 
rather translucent and porcelain-like in appearance, and begins upon the 
retro-tarsal folds coating the inner surface of the lids, but does not invade 
the bulbar conjunctiva. The exudate is often in layers and can be removed 
easily. After the first removal the conjunctiva beneath is only catarrhal 
and does not bleed, but later becomes dark, granular, and bleeds freely. 
The membrane is quickly reproduced, and later there is proliferation of the 
papillary layer of the conjunctiva. The discharge, which may have been 
at first profuse, grows scanty. The cornea, except in severe cases, always 
escapes. 

Diagnosis. — The disease may be confounded with ophthalmia neona- 
torum and diphtheritic ophthalmia. From the former it is to be distin- 
guished by the absence of profuse purulent discharge and the age of the 

1 Inaug. Dissert, Basel, 1887. 



96 AFFECTIONS OF THE EYELIDS, 

patient, and from the latter by the soft swelling of the lids and the super- 
ficial character of the membrane. 

Prognosis, — It is often a light aifection, and in the absence of corneal 
involvement the prognosis is good. Severe cases, however, occur. Healing 
takes place in from ten to thirty days. Occasionally the membrane is 
formed again and again, and the course of the disease may continue for 
months. 

Treatment. — Caustics like nitrate of silver must not be used : Horner 
states that the only case in which he saw corneal ulceration was where 
this drug had been employed. The eyes should be cleansed with a solu- 
tion of boric acid, the membrane removed, and the swelling reduced by 
the application of cold compresses saturated with plain water, or, better, 
with dilute lead -water. After the removal of the membrane, subnitrate 
of bismuth has been dusted upon the surface and yielded good results. 
Quinine has been used in the same way, — a doubtful expedient. The 
presence of corneal complications calls for the same treatment as that 
described under ophthalmia neonatorum. 

DIPHTHEKITIC OPHTHALMIA. 

Synonymes. — Diphtheritic conjunctivitis, Diphtheria of the conjunctiva. 

Definition. — This is characterized by a board-like, very painful swelling 
of the lids ; a scanty sero-purulent or sanious discharge ; an exudation 
within the layers of the conjunctiva, which leads to death of the invaded 
tissues, and tends by spreading to the ocular conjunctiva and by pressure to 
destroy the nutrition of the cornea. 

Etiology. — The disease is contagious, and may originate from a similar 
case or arise in the course of a purulent conjunctivitis : it has occurred, 
though rarely, with ophthalmia neonatorum. In certain localities in the 
south of France and the north of Germany it is endemic. It appears at 
times in connection with eczema of the face and borders of the lids, and, espe- 
cially in the discrete form, is an occasional accompaniment of some acute ill- 
ness like scarlet fever or measles, when the diphtheritic type of the inflam- 
mation becomes engrafted upon the conjunctiva. Finally, the most severe 
forms of the disease are seen during epidemics of diphtheria, and it may be 
part of a process which passes from the nose to the conjunctiva, or be due 
to direct inoculation with the diphtheritic poison. The cause of the disease 
is to be sought in the presence of the micro-organism which is the probable 
origin of the diphtheritic process. The disease is commonest between the 
ages of two and eight years, and is rare in young infants. 

Pathology. — The condition varies accordingly as the inflammation is 
superficial, or deep and parenchymatous. In the former class the dam- 
aged blood-vessels pour out an exudation rich in albumen, which saturates 
the dead epithelial cells, forming a coarse mesh-work, while the subepi- 
thelial layer is invaded by fibrin and leucocytes. In the parenchymatous 
form a greater extent of tissue is affected, and there are coagulation and 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 



97 



Fig. 10. 



death not only of the epithelial but also of the deeper structures. After 
the extrusion of the membrane, healing occurs through granulation-tissue, 
with the formation of cicatrices. Horner has compared the process to the 
destruction produced by a severe lime-burn. The invasion of the mucous 
membrane in this disorder is associated with bacteria, and clusters of micro- 
cocci, as in diphtheria elsewhere, are found. 

Symptoms. — The patches either appear in a discrete form, or the mem- 
brane covers the whole inner surface of the lids, and more rarely, in the 
severe confluent varieties, extends to the ocular 
conjunctiva. The lids are swollen, very painful, 
board-like in hardness, and eversiou is well-nigh 
impossible. The false membrane is of a dull- 
grayish appearance, is torn off only with diffi- 
culty, leaving beneath a raw and bleeding surface 
if the process is superficial, but if it is deep the 
subjacent structure is pale and infiltrated, and 
when cut into may be anaemic and lardaceous. 
If the diphtheritic inflammation has been en- 
grafted upon a case of purulent conjunctivitis, 
the abundant secretion ceases, or becomes thin, 
irritating, and sanious. More than in any other 
disease of the eye the nutrition of the cornea is 
threatened, and all the destructive tendencies 
described with ophthalmia neonatorum are ap- 
parent. In the severe cases sloughing of the cornea is almost inevitable, 
coming on with such rapidity that destruction may take place in twenty- 
four hours. The diphtheritic inflammation may be primary on the con- 
junctiva, or be part of a process which is seen also in the nose and the naso- 
pharynx. If the skin of the face is the seat of eczematous ulcerations, these 
also are attacked and covered with patches of false membrane. 

Restlessness, fever, generally higher in the evening, alimentary derange- 
ments, and nervous phenomena are the usual constitutional disturbances ; 
even fatal cases are on record. When healing occurs, the cornea is found 
almost invariably to have suffered, and leucomata, adherent or otherwise, 
may be expected. Conjunctival cicatrices form, and even extensive sym- 
blepharon. In a remarkable case which I have described, in addition to the 
damage to the cornea the patient exhibited a series of nervous phenomena 
resembling catalepsy.^ 

Diagnosis. — This disorder should be distinguished from croupous 
ophthalmia and from cases of purulent ophthalmia in which coagulation 
of the secretion takes place, with which latter affection it has nothing in 
common. In croupous ophthalmia the lids are supple and painless, the 




Diphtheritic ophthalmia, 
dren's Hospital.) 



df^ 



(Chil- 



Pepper's System of Medicine, v. 316, article on "Catalepsy," by Charles K. Mills, 



M.D. 



Vol. IV.— 7 



98 AFFECTIONS OF THE EYELIDS, 

exudation superficial and easily peeled oif, the surface soft and congested, the 
cornea usually free from injury. In diphtheritic ophthalmia the lids are 
hard and painful, and the exudation removed with difficulty, leaving be- 
neath a pallid and ragged surface, while the whole process tends to mortifi- 
cation of the invaded tissues and destruction of the cornea. The presence 
of an abundant secretion is the distinguishing feature in cases of purulent 
conjunctivitis.^ 

Treatment. — During the earlier stages the best local measures are cold 
compresses applied in the manner already described. If, however, the 
corneal involvement is imminent, or already at hand, hot compresses are to 
be employed frequently for ten to twenty minutes at a time, or even, as I 
did in one of my own cases, well-nigh continuously. The eyes should be 
frequently cleansed with a solution of boric acid or bichloride of mercury 
(one to eight thousand), and atropine drops instilled three times a day, for 
which, if the ulceration of the cornea is peripheral, eserine may be substi- 
tuted. Scarification of the conjunctiva, on account of the speedy infection 
of the spots, is not advisable, and bleeding from the temple in young chil- 
dren is to be avoided. Besides the colly ria mentioned, solutions of sali- 
cylic acid and carbolic acid have found favor. Vossius ^ has recommended 
a four-per-cent. solution of salicylic acid in glycerin to be painted every 
half-hour upon the conjunctiva. Fieuzal^ uses the simultaneous application 
of lemon-juice, which is then washed away, and a two-per-cent. solution of 
nitrate ; and Abadie * speaks of the application of citric-acid ointment as 
preferable to the antiseptics. Galezowski ^ has employed oleum cadini (one 
to ten). Tweedy quinine, and Bergmeister the flowers of sulphur. I tried 
in one case powdered boric acid, but the result was not favorable. In- 
ternally, the most useful remedies are quinine, iron, and mercury ; the 
former should be given in suppositories, the iron as the tincture of the 
chloride, and mercury either as calomel or the bichloride. Of the latter, 
half a grain daily may be continued for days, and should be exhibited in 
milk or water hourly in the dose of one-sixtieth to one-fortieth of a grain 
to children from three to six years of age. Milk punch may be added if 
there is depression, and if naso-pharangeal diphtheria coexists the appro- 
priate local measures are to be used, especially as Jacobi ^ has advised nasal 

1 I have described croupous and diphtheritic ophthahnia as separate forms of conjunc- 
tival inflammation, although many modern writers, like Nettleship, are disinclined to main- 
tain the classical distinction of A. von Graefe, which has also been insisted upon by De 
Wecker, Tweedy, Knapp, and others. It is perfectly true that croupous inflammation and 
superficial diphtheritis, here as elsewhere, are closely related, and Juler has examined micro- 
scopically cases of diphtheritic and membranous ophthalmia and in each found closely 
similar appearances ; nevertheless, although cases intermediate between the two classes 
occur, a sufficient number of each class distinctly marked arise to render the maintenance 
of the differentiation scientifically worthy. 

2 Klin. Monatsbl. f. Augenheilkunde, November, 1881. 
,3 Bull, de la Clin. Nat. Ophth., vol. vi.. No. 2, p. 57. 

* Ibid. ^ Ibid. 

6 Proceedings of the Philadelphia County Medical Society, 1888. 



LACHEYMAL APPARATUS, COXJUXCTIVA, AXD COEXEA. 99 

injections of the bichloride of mercury, one grain to tlie pint. If one eve 
only is attacked, its fellow should be guarded by a bandage in young chil- 
dren, by Buller's shield in older cases. The patient must be isolated, espe- 
cially if other children are at hand Avho are suiFering from facial eczema or 
any form of catarrhal ophthalmia. 

TuBEECLE OF THE CoxjuxcTiVA is a manifestation of a similar affec- 
tion of the lymphatic system of the same side, and by preference has its 
seat upon the palpebral conjunctiva, and rarely upon that of the globe 
(Horner). Examination of the yellowish masses reveals a granular-like 
tissue with giant cells, and Fuchs ^ has observed the presence of tubercle- 
bacilli. The chief symptoms are a somewhat resisting thickening of the 
lids, and upon the conjunctiva, especially between the tarsus and the retro- 
tarsal folds, yellowish or gray-red masses, and sometimes, as Rheim ^ has 
noted in four cases, ulceration with a lardaceous floor. A decided secretion 
is present, and occasionally swelling of the tear-sac and of the neighboring 
lymphatic glands ; the nose may also be involved ; general tuberculosis is 
sometimes absent. The treatment consists in excision of the masses, the 
galvano-cautery, or the application of iodoform in powder or salve. A 
general treatment of tonics, and especially arsenic, is indicated. 

Xeeosis Coxjuxctiv^, — Synonymes. — Keratomalacia, Xecrosis cor- 
nete. Infantile ulceration of the cornea, with Xerosis of the conjunctiva. 

Definition. — This disease is characterized by drying of the conjunctiva 
and destructive ulceration of the cornea, and usually appears in infants 
under one year of age. 

Etiology. — Von Graefe ^ taught that this disorder was dependent upon 
encephalitis, a position M'hich is no longer tenable since the researches of 
Jastrowitz * and Friedlander.^ It occurs only in aneemic, badly-nourished 
individuals. It has been seen accompanying measles and variola, and is 
especially common among sickly children with diarrhoea, and among those 
inmates of homes whose hygienic surroundings are bad. Leber found and 
described a double bacillus, but the researches of Weeks,® Sattler, and others 
have failed to confirm this microbe as the cause of the disease. 

Symptoms. — In the beginning there is conjunctival congestion, with 
lachrymation, but the peculiarity of the disorder is the dryness and lack- 
lustre appearance of the conjunctiva, with the formation of cheesy flakes, 
while the ocular conjunctiva becomes dry, greasy, and is thrown into folds. 
A gray haze rapidly turning into ulceration appears in the cornea, followed 
by involvement of the iris, with the formation of hypopyon. Perforation 



^ Abstract in Archives of Ophthalmology, 1887. 

2 Munch. Med. Wochenschi-., 1886, Nos. 13 and 14. 

=* Archiv f. Ophth., Bd. xii. Abth. ii. p. 2-50. 

* Archiv f. Psych, u. Nervenk., Bd. ii. S. 389; Bd. iii. S. 162. 

5 Berlin. Klin. Wochenschi-., 1883, Xo. 6, S. 90. 

^ Archives of Ophthalmology, 1886, vol. xv. p. 332. 



100 



AFFECTIONS OF THE EYELIDS, 



Fig. 11. 



and destruction of the eyeball may result. Both eyes, as a rule, are affected, 
— one earlier than the other. 

Prognosis. — This is very unfavorable, not only in so far as the eye is 
concerned, but also in regard to the lives of the patients : they usually die 
of the wasting disease which has occasioned the trouble, or of an intercurrent 
pneumonia. 

Treatment. — This resolves itself, besides the local measures of cleanli- 
ness, with antiseptic washes and the use of atropine, into the administration 
of such internal remedies as are called for by the general state of the 
patient. 

Essential Shrixkixg of the Coxjuxctiva is a rare disease, in 
which this membrane atrophies and undergoes contraction until the con- 
junctival cul-de-sac disappears and the 
free borders of the lids are fixed to the 
ball ; through exposure the cornea be- 
comes dry and opaque. The process has 
been mistaken for granular lids, with 
which, however, it has no association. 
Some have believed this to be a form of 
pemphigus of the conjunctiva, and iS'et- 
tleship {loc. cit.) has seen this condition 
accompany an outbreak of general pem- 
phigus. In other cases no association 
of this kind was found, and Juler^ thinks 
essential shrinking of the conjunctiva and 
pemphigus quite distinct processes ; there 
is occasional coincidence of the two affec- 
tions in the same patient. I have ob- 
served an instance of this character in 
a child the subject of hereditary syphilis, who died of phthisis.^ 

Treatment. — This avails but little. It has been attempted to keep the 
conjunctiva moist with glycerin, and rabbit's conjunctiva has been trans- 
planted, but without result. 

Pemphigus of the Conjuxctiva is a rare affection, characterized 
by the formation of bullae associated with pain and lachrymation, and, after 
succeeding attacks, degeneration and cicatrization of the conjunctiva. It is 
doubtful whether this occurs as an independent disorder ; it is usually seen 
in connection with pemphigus of the rest of the body. The course of the 
disease, which tends to recur from time to time, is destructive to the nutri- 
tion of the conjunctiva, and later of the cornea. The former undergoes 
cicatricial change and may grow fast to the ball ; the latter becomes opaque 
and staphylomatous. Interesting examples of this affection in children 




From a photograph of a patient sufFering 
from essential shrinking of tlie conjunctiva. 
(Children's Hospital.) 



1 Transactions of the Ophthalmological Society of the United Kingdom, 1886. 

2 Transactions of the Pathological Society of Philadelphia, vol. xiii. 



LACHRYMAL APPARATUS, COXJUNCTIVA, AND CORXEA. 101 

have been reported by Cohn/ by Baeumler,^ and, in this country, by Tilley/ 
who has well described one of the three American cases. 

Treatment. — This is practically of no avail. Sight, if lost through 
this disease, cannot be restored, and the best that can be accomplished is 
relief of the local irritation. 

Xerosis (Xerophthalmos) is the name employed by systematic writers 
to describe the dry, lustreless, and shrunken appearance of the conjunctiva 
which may appear either in the parenchymatous or in the epithelial form. 
The former variety occurs under the influence of trachoma and pemphigus, 
or in the form of a primary disease just described as essential shrinking of 
the conjunctiva. The epithelial type of the disorder is seen with infantile 
necrosis of the cornea (page 99), and in debilitated subjects, accompanied 
by night-blindness (which see). 

Lupus of the Coxjuxctiva occurs as a primary disease or extends 
to the membrane from the surrounding integument (page 60). It appears 
in the form of red, granulation-like patches. In a case reported by Grand- 
mont,* inoculation experiments with the excised growth resulted in ap- 
pearances similar to those produced where tuberculous human lung was 
employed. 

Amyloid Degexeratiox of the Coxjuxctiva is a rare disorder, 
in which pale-yellowish masses appear chiefly in the palpebral conjunctiva. 
It has been supposed to arise from granular ophthalmia, but, according to 
Raehlmann, these growths are independent of trachoma. They disappear 
after extirpation, which is the proper treatment, and their structure is the 
same as that of lymphoid tumors in which a hyaline degeneration may be 
found, which is in all probability an antecedent condition. 

Chemosis of the Coxjuxctiva occurs when the connective-tissue 
layer is distended with serum, and is often associated with inflammatory 
exudate. It is mostly a symptom of some other disease, — for example, 
acute conjunctivitis, choroiditis, iritis, or orbital cellulitis. Severe cedema of 
the conjunctiva, with great swelling and hyperemia, may appear without any 
apparent cause and Avith marked suddenness. In paralysis of the external 
straight muscles the overlying conjunctiva is often decidedly oedematous and 
may be an early symptom of such an accident. I have seen acute chemo- 
sis ^ in young adults follow the administration of ascending doses of iodide 
of potassium, and in one instance succeed a general outbreak of urticaria. 

Treatment. — The swelling may be reduced by the application of cold, 
possibly by pricking the tissues, and later by the use of some astringent, like 
alum. 

Hemorrhage from the Coxjuxctiva. — This usuallv occurs as an 



1 Abst. in Archives of Ophthalmology, 1886, p. 120. 
■■^ Klin. Monatsbl. f. Augenheilkunde, vol. xxiii. p. 329. 
^ American Journal of Ophthalmology, June, 1887. 

* Annual of the Universal Medical Sciences, 1889, vol. iv. 

* American Journal of Ophthalmologj', December, 1887. 



102 AFFECTIONS OF THE EYELIDS, 

ecchymosis beneath the conjunctiva sclerse, the meshes of the connective 
tissue being filled with blood-clot as the result of some violent straining 
during a paroxysm of whooping-cough. It may arise from injury or with- 
out obvious cause, and has been seen occurring spontaneously about the 
menstrual epoch in young girls. Pomeroy ^ has recorded a well-nigh fatal 
hemorrhage following the instillation of nitrate of silver, and Schmidt- 
Rimpler,^ has seen death follow hemorrhage from this membrane, but the 
cause of the bleeding was not determined. Ordinarily, subconjunctival 
hemorrhage will subside by absorption, and requires no treatment. 

Pterygium is a hypertrophic fold of conjunctiva extending from the 
periphery of the globe towards the edge of the cornea. It varies in color 
and thickness according to the amount of hypertrophy and the presence of 
blood-vessels. Its most frequent situation, corresponding to the course of 
the recti muscles, is at the inner side of the eyeball, more rarely at the outer, 
very exceptionally at the upper or lower. The disease, never of frequent 
occurrence, is rare in children. Individuals whose occupation exposes them 
to slight injuries of the eye are predisposed to its formation. Poncet has 
described microbes in connection with the formation of pterygia. They 
occasionally arise as the result of a blennorrhoea, during which the con- 
junctiva has become attached to a corneal ulcer. Kuapp {loc. cit.) has re- 
ported one such case where the pterygium had the superior situation after 
purulent ophthalmia. Thickenings of the conjunctival membrane in all 
particulars resembling pterygium have been described as congenital affections. 
In one such case, recorded by Strawbridge,^ the growth sprang from the 
outer commissure and covered the corneee to fully one-half their surface. 
The treatment consists either in excision, transplantation, strangulation by 
means of a ligature, or evulsion as recommended by Prince. 

Tumors of the Conju:n'ctiva. — As congenital forms, angiomas, 
lymphangiomas, dermoid growths, and pigmented spots have been de- 
scribed. Although the latter may be congenital, it should be remembered 
that they appear after the healing of variolous pustules when they occur 
upon the conjunctiva. The other tumors which have their habitat upon the 
conjunctiva are lipoma, fibroma, osteoma, papilloma, and sarcoma. Lipoma, 
according to Von Graefe, appears to be most common in the region between 
the superior and the external rectus, and may be mistaken for the dermoid 
growth (Horner). Osteomas appear as small nodules of bone surrounded 
by fat and firm connective tissue (Snell, Schweigger). Loring * saw a case 
of this nature in a child eight months old. Papilloma arises from the limbus 
conjunctiva. I have seen one instance apparently follow a burn of the con- 
junctiva.^ Cysticerci have been extracted from the subconjunctival tissue 

1 New York Medical Kecord, August 20, 1887. 

2 Klin. Monatsbl. f. Augenheilkunde, October, 1887. 

^ Transactions of the American Ophthalmological Society, 1873-1879, vol. ii. p. 386. 

* Archives of Ophthalmologj^, 1883, p. 523. 

* Transactions of the Pathological Society of Philadelphia, 1886. 



LACHRYMAL APPARATUS, COXJUNCTIVA, AND CORNEA. 103 

of children by Makrocki/ Hirschberg/ and others. Sarcoma, both of the 
pigmented and the nnpigmeuted variety, occurs, usually the former, and gen- 
erally arising from the bulbar conjunctiva. FielchenfekP has described an 
unpigmented sarcoma of the conjunctiva palpebrarum in a girl of sixteen.* 
Treatment. — Excision of these growths is the only treatment, either 
alone or in addition to cauterization of their bases. In sarcoma of the con- 
junctiva it will be necessary to discuss the propriety of enucleation of the 
entire eye. 



AFFECTIONS OF THE COENEA. 

Equal in importance to the group of diseases just concluded are the 
affections of the cornea. In Horner's statistics they constitute twenty-seven 
and two-tenths per cent, of the whole number, and among one thousand 
seven hundred and eight recorded cases in the Children's Hospital of this 
city twenty-five and six-tenths per cent, were treated for the various dis- 
orders of the cornea. Many types of corneal inflammation exist, and, al- 
though it is customary to divide these diseases into suitable groups, it is by 
no means possible to refer in each instance to one or other of these divisions. 
Under the general term keratitis we include the divers forms of inflamma- 
tory affections of the cornea, and to all of them, if ulceration is present, 
certain well-marked symptoms belong, — pain, congestion of the vessels of 
the circumcorneal area, photophobia and blepharospasm, and loss of the 
substance or transparency of the cornea. 

PHLYCTENULAE KEKATITIS. 

Synonymes. — Strumous keratitis. Pustular keratitis. Vesicular kera- 
titis. 

Definition. — This is characterized by the formation upon some portion 
of the cornea of small papules or pustules, and is accompanied by dread 
of light and blepharospasm. 

Etiology. — The disease is quite constantly seen in strumous subjects. 
It often follows in the wake of an attack of measles or other acute ex- 
anthem. It is distinctly under the influence of climate, and is usually ag- 
gravated by warm, moist weather. Micro-organisms probably play a role 
in its production, and Burchardt^ has described cocci Avhich greatly resembled 
the coccus flavus desidens (Fluegge) and to which he attributed a causative 
action. There is a close connection, between this form of keratitis and in- 
flammatory lesions existing in the nasal fossa which are the source of an 

1 Abst. in Archives of Ophthalmology, 1884, p. 484. 

2 Centralblatt f. prakt. Augenheilkunde, June, 1879. 

3 Ibid., April, 1888. 

* For syphilitic diseases of the conjunctiva, see Diseases of the Eyelids, page 57. 
^ Centralblatt f. prakt. Augenheilkunde, February, 1887. 



104 AFFECTIONS OF THE EYELIDS, 

infectious pus. Thus, in twenty-six observations Augagneur ^ found the 
phlyctenules on the cornea succeeded a rhinitis of this character. Martin ^ 
has attempted to demonstrate a relation between keratitis and astigmatism. 

Symptoms. — The phlyctenules, which consist in the early stage of 
minute subepithelial collections of round cells, appear upon the cornea 
usually at or near the corneo-scleral junction. They vary in size from a 
poppy-seed to a millet-seed ; their tops, at first gray, speedily grow yellow, 
break down, and form superficial ulcers. They are accompanied by decided 
local congestion, increased lachrymation, and photophobia. The palpebral 
conjunctiva, always hypersemic, may remain translucent and bathed in tears, 
or the disorder is not infrequently accompanied by muco-purulent discharge 
and a velvety condition of the conjunctiva, under which circumstance it is 
spoken of as phlyctenular keratitis with catarrh. When the photophobia is 
severe, the child buries its head deeply in the bedclothes ; the lids are spas- 
modically closed, rendering inspection of the eye difficult, at times well-nigh 
impossible. The dread of light and the blepharospasm are probably due to 
direct irritation of the corneal nerves, as Iwanoff found the cellular infiltra- 
tion situated along the course of the nerves. The pustule, when it breaks 
down, forms a jMyctenular ulcer, which may remain at its original seat 
near the margin, or creep towards the centre of the cornea, followed by a 
bundle of thickly-crowded blood-vessels (fascicular keratitis). These, when 
the ulcer heals, disappear, but a stripe of opacity remains. Under the 
name marginal keratitis a variety of this inflammation exists where numer- 
ous phlyctenules extend along the rim of the cornea, giving rise to a process 
which may cease here, or may by further invasion produce vascular ulcers. 
More dangerous than any of the other varieties is the formation of a single 
pustule just at the corneal border, which speedily ulcerates and is surrounded 
by a yellow area of infiltration, with a strong tendency to perforate. If 
these inflammations constantly recur, the cornea becomes clouded, uneven 
from loss of epithelium, and covered by numerous superficial vessels, the 
whole forming the so-called jMyctenular pannus. 

Diagnosis. — This presents no difficulties, the appearance by direct 
inspection rendering the nature of the disease evident. 

Prognosis. — The course varies greatly ; in mild cases healing takes 
place with only a slight loss of substance, and the resulting scar is scarcely 
discernible. Not so with the severe forms, in which there has been decided 
loss of substance and a distinct scar-tissue remains, or in which deep ulcer- 
ation with perforation occurs, or where constantly-recurring vascular ulcera- 
tion leaves an uneven and roughened surface. In children of the strumous 
type, especially if their surroundings are unfavorable, phlyctenular keratitis 
may be one of the most stubborn of corneal diseases. 

Treatment, — In order to make a thorough application of the local 



1 Kecueil d'Ophtalmologie, October, 1888, p. 631. 

2 Amiales d'Oculistique, torn. xc. pp. 14, 176 ; torn. xci. pp. 44, 209. 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 105 

remedies, the child's head should be taken between the surgeon's knees, 
while the attendant holds the hands and body, and the lids are separated : 
the cornea will usually roll out of sight, but may gradually be coaxed into 
view. Sometimes a lid-elevator is useful, and a few whiflPs of ether or 
of chloroform may be necessary. If much secretion is present, boric acid 
solution is to be employed, and atropine drops sufficient to maintain 
mydriasis. Cocaine, judiciously used, will allay the photophobia, but 
its continuous application when corneal ulcers exist is to be deprecated. 
Later, an ointment of the yellow oxide of mercury, either with or without 
the addition of atropine, or calomel, provided no form of iodide is being ex- 
hibited, dusted into the conjunctiva, may be employed. The eyes should be 
protected with goggles, and the child encouraged not to bury its head in the 
bedclothes. The best possible hygienic surroundings must be obtained, 
with fresh air and wholesome food. Cod-liver oil, iron, quinine, often 
suitably given with pepsin, and arsenic, are the most acceptable internal 
remedies. Douching the eyes with cold water will subdue the dread of 
light, and touching the ulcerated external commissure, which almost in- 
variably exists in these cases, Avith a crystal of bluestone, as Roller {loo. 
cit.) has suggested, helps to relieve the blepharospasm. The urine should 
be examined in all these cases ; and scrupulous attention to the condition 
of the alimentary canal is an important factor in the treatment. If rhinitis 
is present, this must be attended to : for this purpose Augagneur employs 
a powder composed of equal parts of pulverized camphor, boric acid, and 
subnitrate of bismuth. I can recommend this treatment, especially if the 
nasal fossae are thoroughly cleansed with Dobell's solution before the 
insufflation of this powder. In stubborn forms of recurring vascular ulcer 
and deep ulceration, the use of the thermo-cautery in the manner later 
described is productive of excellent results. After healing, any refraction- 
error should be corrected. 

COKNEAL ULCEES. 

In addition to the varieties of corneal ulcers just described, others 
remain which may be classified under four headings : 

1. Small Central Ulcer. — This appears as a gray or gray-white opacity 
in the centre of the cornea, and is not accompanied by much vascularity 
or dread of light. The elevation is slightly cone-shaped until the whitish 
top breaks down into a shallow depression. Usually single, this form of 
ulcer may be multiple, and under any circumstances it tends to recur. It is 
seen in young children who have been poorly nourished and are of a stru- 
mous habit. While healing generally occurs with promptness, the tendency 
to recurrence leaves permanent opacity, which, from its central situation, 
may seriously impair vision. If neglected, and in patients of bad nutrition, 
this ulcer occasionally forms an abscess of the cornea. 

2. Excavated or Gouged-out Ulcer. — This form of ulcer, often seen in 
children, most troublesome because it is so rebellious to treatment, has its 



106 AFFECTIOXS OF THE EYELIDS, 

seat near the corneal margin. Its presence may be entirely overlooked, on 
account of the absence of congestion, and because in appearance it is a small 
punched-out excavation, with transparent bottom and free from any opaque 
surrounding infiltration. The disease probably depends upon some failure 
in the nutrition of the cornea due to nervous disturbance. When healing 
is about to take place, the floor of the ulcer loses its translucency and a few 
vessels of repair pass to its margin. 

3. Shallow Central Ulcer. — In a certain number of cases a shallow 
nearly central ulcer appears, with a slightly turbid base, unattended with 
any considerable pain or photophobia. It is essentially chronic in its 
course, and when healing finally takes place a faintly opaque facet remains. 
It is found in aneemic or scrofulous patients, and is occasionally seen in 
subjects of long-standing granular lids. 

4. Infecting or Sloughing Ulcer {Purulent Keratitis). — Ulcers unattended 
by vessels of repair, which spread widely from one border and become 
readily complicated with hypopyon and iritis, and which are often the re- 
sult of a trifling injury, usually affect elderly people and those whose nutri- 
tion is depressed. Most important among these are the serpiginous or creep- 
ing ulcer of Saemisch, and the circular ulcer. But sloughing ulcers are not 
confined to aged subjects : the small central ulcer, as already noted, may 
spread and form an abscess. Usually in the early stage a nearly central 
gray area forms, over which the epithehum may be unbroken, though dis- 
colored. This speedily becomes yellow, notches laterally, bulges forward, 
and finally bursts entirely, leaving a more or less ragged ulcer covered with 
tenacious pus and forming the condition spoken of as abscess of the cornea ; 
or it may evacuate posteriorly and cause a collection of pus in the lowest 
part of the anterior chamber, or an hypopyon. This combination of sup- 
puration in the cornea with pus in the anterior chamber is often called hyj^o- 
pyon-keratitis, a name originally suggested by Roser, while onyx is the term 
applied to that condition when the suppuration passes between the layers of 
the cornea and settles in its most dependent portion. Purulent keratitis is 
usually accompanied by severe pain in the brow, the eye is intensely tender, 
and the vision is reduced to mere light-perception. The iris becomes hy- 
persemic, inflamed, and posterior synechiee form if unchecked ; the entire 
cornea is reduced to a softened mass, which, when it separates, allows the 
iris to fall forward and become adherent in the lymph which ultimately 
closes the aperture, and all the results of perforation follow. (See page 80.) 

Etiology. — Sloughing ulcers of the character described are dependent 
upon local infection, and most frequently result from an injury to the cornea 
from a chip of stone, a chestnut-burr, or the like, which of itself may cause 
an insignificant wound, but, in an individual unfavorably disposed to kind 
healing, may terminate, through the microbic infection, in this dangerous 
form of inflammation. A certain number of cases have been ascribed to 
cold, and in still others no definite cause can be ascertained. Most violent 
forms of suppurative keratitis occur during attacks of small-pox ; the pus- 



LACHRYMAL APPARATUS, COXJUXCTIVA, AND CORXEA. 107 

tales, however, rarely form upon the cornea. Indeed, it has been said that 
they are never so situated, though Horner in one instance observed a single 
ulcer the origin of which he believed to have been a corneal pustule. 

Abscess of the cornea occasionally accompanies scarlatina, measles, and 
typhoid fever ; its association with violent types of conjunctival inflamma- 
tion has already received attention, A variety of abscess of the cornea, 
non-inflammatory in character, has been described by Von Graefe ^ as occur- 
ring in scrofulous children under eight years of age, without any healing 
tendency and with almost an entire absence of subjective symptoms. The 
character of the inflammation and the constitution of its subjects have led 
some to consider it a form of tuberculosis of the cornea, the possibility of 
which the experiments of Panas and Vasseaux ^ have demonstrated. 

Results of Corneal Ulceration. — Opacities more or less permanent 
follow all ulceration of the cornea. If the opacity is slight, it is spoken 
of as a nebula or macula ; if dense, as a leucoma, which, accordingly as the 
iris is or is not attached to its posterior surface, is described as adherent or 
non-adherent. It is evident that upon the position of the opacity in the 
cornea depends its influence upon vision. The more central it is, or rather 
the more directly it encroaches upon the pupillary region, the greater will 
be the disturbance of direct vision. Irregularities in the curvature of the 
cornea distort the retinal images and are fruitful sources of mixed astigma- 
tism. When perforation has followed ulceration and the iris has remained 
entangled in the aperture, an anterior synechia results. An eye thus 
afflicted may become quiet, and even retain, either with or without operative 
interference, useful vision ; but it may equally well be a continual source 
of annoyance, subject to recurring attacks of inflammation, and breed sym- 
pathetic irritation in the fellow-eye. 

The distention of a cicatrix to whose inner surface the iris is attached 
constitutes a corneal staphyloma, which is called total when the entire cornea 
is involved, and partial when only a portion is 
included. The mechanism of this formation is ^^*^' ^'^■ 

briefly as follows. A perforation takes place, and 
the iris falls forward and attaches itself to, or pro- 
trudes through, the opening, becoming fixed there 
by the lymph thrown out in the process of repair. 
The scar-tissue which remains fails to withstand 
the intraocular tension, and that portion of the 
cornea is pushed forward beyond its normal cur- 
vature, forming a pouch-like deformity, or per- staphyloma of the cornea. 
chance including its entire surface. The protru- 
sion may flatten down, and under the influence of fresh inflammation bulge 
forward again, or may extend between the palpebral fissure and prevent 
the lids from closing. 




1 Archiv f. Ophth., vi. 2, 135. ^ ^pch. d'Oph., 1885, v. 193. 



108 AFFECTIOXS OF THE EYELIDS, 

Treatment of Ulcers of the Cornea. — It is manifestly impossible to 
lay down hard-and-fast lines for the treatment of corneal ulceration ; this 
must be governed by the exigencies of each case ; but certain principles of 
local treatment are common to the various types. 

Pain, photophobia, and congestion are to be relieved by the plans 
already suggested in treating of phlyctenular keratitis. In mild cases 
atropine, combined, with due caution, with cocaine, a lotion of boric acid, 
and a pair of smoked glasses usually suffice. In chronic cases a seton in 
the temple has been advised. 

After the subsidence of the acute symptoms, or when the ulcer from 
the beginning is unaccompanied by these, local stimulation should be prac- 
tised. This is best done with an ointment of the yellow oxide of mercury, 
a small portion being introduced between the lids morning and evening. 
Calomel dusted into the eye is likewise of excellent repute, provided the 
patient is not taking iodide of potassium. Direct stimulation of the ulcer 
with nitrate of silver (five grains to the ounce) has been recommended, — 
an application of great value if cautiously and properly used. Whenever 
corneal ulceration is accompanied by conjunctivitis, the inner surfaces of 
the lids should be daily brushed over with a weak solution of nitrate of 
silver, and the cul-de-sac carefully cleansed with a boric-acid solution or 
the collyrium of bichloride of mercury. 

In all forms of severe corneal ulceration, in sloughing and spreading 
ulcers, either with or without hypopyon, other and more decided methods are 
applicable. It has been and is a universal practice to instil atropine drops, 
because of their anodyne effect, and because they lessen the liability to 
iritis, mitigating at the same time the severity of the inflammation through 
their power to contract the vessels of the ciliary region and diminish the 
supply of nutritive material to the cornea. In many cases, however, 
eseriue is the better drug, either because it has the power of stopping the 
migration of white blood-corpuscles, or promotes absorption through dila- 
tation of the ciliary vessels, or acts locally upon the ulceration, limiting the 
sloughing process. Furthermoi'e, if the tension is raised, it lowers this, 
but not otherwise. The solution employed may be from one-half to two 
grains to the ounce. Deep ulcers near the margin of the cornea are those 
most suitable for its application. Pain is relieved and the process of repair 
encouraged by the frequent application of hot compresses in the manner 
already described. (See page 83.) 

When by extension of the ulcer perforation of the cornea is imminent, an 
antiseptic compressing bandage should be applied, to be removed when the 
necessary local applications are made. Long-continued use of the bandage 
is often followed by the appearance of an eczematous eruption upon the 
skin of the lids. This should be treated by dusting the parts with calomel. 
Catarrh of the conjunctiva contra-iudicates the use of the bandage unless 
the danger of perforation is imminent. 

If, in spite of such treatment, the local infection continues to spread, 



LACHRYMAL APPARATUS, COXJUXCTIVA, AXD CORNEA. 109 

this must be checked by scraping Or l)y the use of the actual cautery. The 
latter may be either a small Paquelin or galvauo-cautery : wheu neither of 
these is at hand, a knitting-needle or platinum probe, as recommended by 
Grueniug, heated white-hot in the flame of a Buuseu burner, will suffice. 
The edge and afterwards the floor of the ulcer should be well burned, and, 
as Mr. Xettleship has suggested, the burn may be extended a trifle beyond 
the edge. In like manner an ulcer may be carefully scraped with a blunt 
curette and thus stimulated to healing. Cocaine renders either of these 
little o^Derations painless ; but in young and restless children a few whiffs 
of ether are necessary. I have had the most satisfactory results with the 
actual cautery, and recommend the treatment. After both of these methods 
iodoform should be dusted into the conjunctival cul-de-sac. The direct 
application to the floor of the ulcer of a solution of nitrate of silver has 
already been referred to, and has many advocates. 

The formation of an abscess of the cornea or of an hypopyon is the 
signal for the evacuation of the pus. This may be clone by a simple para- 
centesis of the cornea in its lower portion, or by the more formal procedure 
of Saemisch, in which a cataract-knife is entered on one side of the cornea 
with its cutting edge upward, carried across the anterior chamber to the 
other side of the ulcer, and the section made directly through the diseased 
area, evacuating thus at the same time the collection of pus in the layers of 
the cornea and at the bottom of the anterior chamber. A great objection 
to this operation in children is the difficulty of keeping them quiet after its 
performance, and thus increasing the liability, always present, of prolapse 
of the iris. Moreover, it is surprising how in them absorption of the 
products of an hypopyon keratitis will follow the non-operative treatment 
already described. The use of the actual cautery has largely substituted 
the operation of Saemisch. 

If perforation occurs, and the vigorous use of atropine or eserine, accord- 
ing to the situation, fails to restore the prolapsed iris, this should be drawn 
forward through the aperture and excised, or, in the event of a failure, 
a later iridectomy may be made through an incision in another part of the 
cornea. The most useful antiseptics during corneal ulceration are boric 
acid, bichloride of mercury (one to eight thousand), and iodoform in the 
form of a salve. Stimulating drops of laudanum or chlorine-water are 
occasionally employed. According to Dehenne ^ and others, irrigation of 
the lachrymal canal with a four-per-cent. solution of boric acid is of material 
aid in treatment. 

Constitutional Treatment. — Attention to hygiene, diet, and judicious 
internal medication are of paramount importance. The child should not 
be penned up in a dark room, but, with the eyes properly protected with 
goggles, should go out into the fresh air every day. The diet must be nutri- 
tious and easily digested : tea, cofl^ee, candies, and pastries are to be strictly 

1 Kecueil dOphtiilmologie, 1887, pp. 20.5-210. 



110 AFFECTIONS OF THE EYELIDS, 

forbidden. If struma is present, cod-liver oil, lacto-phosphate of lime, and 
iodide of iron are indicated ; anaemia is best treated with the tincture of the 
chloride of iron ; any suspicion of malarial taint requires the use of quinine 
and arsenic, while the syphilitic heritage calls for the iodides and mei'cury, 
especially in the form of the bichloride ; the best laxative is calomel. The 
urine should be carefully examined for albumen and for the products which 
indicate imperfect assimilation, and the remedies directed according to the 
findings. The teeth should always be inspected, and, if faulty, the case 
turned over to a competent dentist. Bad teeth and proper mastication 
and digestion of the food are not compatible, and the occasional rela- 
tion of carious teeth to diseases of the eye is too well established not to 
render their examination in all cases of corneal ulceration most necessary. 
In young children the irritation of a new dentition has caused abscess of 
the cornea, and in the hands of Galezowski ^ the simple lancing of the gums 
in an eighteeu-months-old child was followed by a cure of the corneal ulcer- 
ation. I have more than once obtained valuable results by such methods.^ 
Careful inspection of the naso-pharynx is necessary here, as well as in dis- 
eases of the lachrymal apparatus and conjunctiva. This is especially true 
in the cases of phlyctenular keratitis which are so often accompanied by an 
irritating rhinitis. For this purpose I have found the powder recommended 
by Augagneur {loc. cit.) very serviceable. (See page 105.) 

Treatment of Results of Corneal Ulceration. — Opacities, especially in 
young children, will often clear up in a surprising manner. By far the 
most satisfactory results follow massage of the cornea, as originally intro- 
duced by Pagenstecher and recommended by Snell,^ Pfalz,* and others. 
The massage movement should be made upon the closed lid of the cornea 
after the introduction of a small piece of the yellow oxide of mercury salve. 
Some irritation accompanies the method, which may be allayed by the occa- 
sional use of a boric acid and cocaine wash. I have employed massage of 
the cornea with excellent results.^ 

Dense leucoma cannot be influenced by such practice. Here vision may 
be improved by an iridectomy for a new pupil, and the appearance of the 
eye improved by tattooing the cornea with India ink, or, as has been recom- 
mended by Vacher, De Wecker, and Levis, the colorings of the iris may be 
imitated by using for this purpose many colored pigments. In recent years 
attempts have been made at transjDlantation of the rabbit's cornea for the 
relief of these central opacities, and the results of Von Hippel have in one 
or two instances been encouraging. Martin of Bordeaux, and Strawbridge 
of this city, have proposed under similar circumstances to trephine the 
sclera, and thus create a new pupil. 

1 Journal d'Ophtalmologie, tome i. p. 606. 

^ University Medical Magazine, October, 1888. 

3 Ophthalmic Review, 1888. 

* Editorial in Medical News, February 23, 1889. 

•^ University Medical Magazine, September, 1889. 



LACHRYMAL APPARATUS, CO^'JUXCTIVA, AND COKXEA. Ill 

In partial staphyloma of recent date a compressing bandage is to be 
applied and eserine drops used daily. If, in spite of this, the bulging con- 
tinues, paracentesis of the anterior chamber, or an iridectomy opposite the 
clearest part of the cornea, may be performed. When the staphyloma is 
complete and unsightly, or if it is the seat of pain, is a source of danger to 
the fellow-eye, and its vision is destroyed, excision of the globe is indicated, 
an operation which in children is likely to be followed by a good deal of 
deformity, owing to the shrinking of the orbit and a failure of development 
of the bones upon that side. Various substitutes for the excision of the eye- 
ball are practised. Abscission, or the removal of the staphylomatous cornea, 
leaves a movable stump for carrying an artificial eye. Evisceration is 
highly recommended by Mules of Manchester and Graefe of Holland. 
Optico-ciliary neurotomy is an operation not free from danger, and not to 
be recommended. 

VASCULAK KEEATITIS. 

Vascular keratitis is a superficial vascularity and opacity of the cornea, 
and is seen in pannus caused by granular lids (page 90), and in the phlyc- 
tenular pannus the result of many relapses of phlyctenular keratitis (page 
104). Another and the true form of vascular keratitis is characterized 
by the formation of two opposite vascular areas at the upper and lower 
margins of the cornea, which approach each other until the vasculari- 
zation is complete. This disease is met with in young adults and in 
unhealthy and underfed children. The second eye is usually attacked, and, 
as Mr. Carter ^ has pointed out, the anatomical disorder indicates a per- 
verted action of the nerv^es which govern the areas affected, and places it 
in an analogy with herpes. The symptoms begin insidiously with slight 
intolerance of light, preceding the appearance at the upper margin of the 
cornea of a crescent of closely-arranged blood-vessels, which as they advance 
push before them a border of corneal opacity. Simultaneously the same 
appearances become manifest at the lower margin. Clearing begins at the 
borders, and the whitish opacity which remains leaves the centre last of all. 
The diagnosis is readily made by the appearances pointed out, but in its 
early stages the lesion may be mistaken for an ordinary conjunctivitis. All 
the cases must be regarded with anxiety, and some do not clear up entirely. 

Treatment. — The principles already laid down with reference to proper 
diet and exercise should be practised. All local irritants are contra-in- 
dicated, but atropine and cocaine and warm fomentations are indicated 
during the acute stages ; later, the yellow oxide salve and calomel may be 
tried. The best internal treatment is a prolonged course of iron and bi- 
chloride of mercury. Iridectomy for a new pupil may be necessary, and, 
as Mr. Carter has suggested, the convex side of the vascular crescent may 
be touched with the galvano-cautery. 

1 Ophthalmic Surgery, by K. B. Carter and W. A. Frost. 



112 AFFECTIONS OF THE EYELIDS, 

INTERSTITIAL KERATITIS. 

Synonymes. — Syphilitic, Inherited, Specific, Parenchymatous, Stru- 
mous, and Diffuse Interstitial keratitis. 

Definition. — This is a diffuse keratitis in which a chronic inflammation 
of the whole thickness of the cornea takes place, until, without ulceration, 
the cornea passes into a condition of universal thick haziness. 

Etiolog-y. — The majority of cases of interstitial keratitis, as was origi- 
nally pointed out by Hutchinson,^ are due to inherited syphilis ; in rare in- 
stances, to acquired syphilis. In spite, however, of the not infrequent 
occurrence of this affection, which composes, according to Horner {loc. dt.), 
one-half per cent, of all gathered eye-diseases, and which Hirschberg^ has 
found six times in each one thousand cases among sixteen thousand eight 
hundred observations in eye-disorders, the proof of the cause is not alwavs 
of ready demonstration. This must be searched for in the family history, 
the accompanying symptoms, and the affected eye. 

Nettleship,^ writing concerning this point, says, " I have found further 
personal evidences of inherited syphilis in fifty-four per cent, of my cases 
of interstitial keratitis, and evidence in the family history in fourteen per 
cent, more ; total, sixty-eight per cent. ; and in most of the remaining 
thirty-two per cent, there have been strong reasons to suspect it." The 
percentage of cases in which inherited syphilis is the cause is given by 
Saemisch as sixty-two, Horner sixty-two, Michel fifty, and Hirschberg 
sixty-one, and according to the latter observer the percentage would prob- 
ably be higher if the separation of typical cases was made from such as 
were similar in appearance.* A. Trousseau,^ among forty cases of inter- 
stitial keratitis, found three only in which syphilis could be positively ex- 
cluded. On the other hand, the influence of hereditary syphilis in the 
causation of this disease has been called in question by a number of ob- 
servers, and Panas, because of the configuration of the teeth, has sought to 
bring the disorder in association with rachitis. 

Poncet,® Javal,^ and Landolt ^ have seen interstitial keratitis result from 
malarial cachexia, and Sedan^ of Toulon analyzed thirty-four cases, finding 
sixteen times syphilis of the parents, nine times scrofula of the patients, 
and twenty-seven times malaria. I have seen two cases of this disorder of 
quite typical course, in one of which inherited syphilis was present, but in 
the other this could not be demonstrated. In both malaria was evident by 
direct history and by periodical temperature-ranges. Struma, however, as 

^ Ophthalmic Hospital Reports, vol. i. 

^ Centralblatt f. prakt. Augenheilkunde, July, 1888. 

3 Diseases of the Eye, 1887, p. 142. 

* These figures are taken from Hirschberg, loc. cit. 

5 Progres Med., May 14, 1887 ; Centralblatt, May, 1887. 

^ Soc. fran9. d'Ophth., 1887, abst. in Archives of Ophthalmology, 1888, vol. xvii. 

-^Ibid. 8 Ibid. 

* Recueil d'Ophtalmologie, September, 1887. 



LACHRYMAL, APPARATUS, COXJUXCTIVA, AND CORXEA. 113 

Nettleship and others have shown, probably does not in any way originate 
this disease, because its subjects are not oftener scrofulous than other chil- 
dren, nor do strumous children suffer more from this form of keratitis than 
from others, while the well-recognized scrofulous eye-diseases are seldom 
associated with this form of diffuse keratitis. 

It is most frequently seen between the ages of five and fifteen, occasion- 
ally as early as three years, bat rarely after thirty. Among one hundred 
observations Hirschberg (foe. cit) found thirty-one cases in the first decade, 
thirty-seven in the second, and sixteen in the third. Power ^ states that an 
examination of the ward-books of the Ophthalmic Department of St. Bar- 
tholomew's Hospital shows interstitial keratitis to be more frequent in 
females than in males : the average age for males to be attacked is 17^ 
years, while the average for females is 15f-|- years; whence it is seen that 
women are attacked a year and a half earlier, the average being reduced 
by the greater number of cases occurring about the supervention of men- 
struation. The greater immunity of the male sex from this disease does not 
appear in the statistics of A. W. W. Baker and J. B. Story,^ where in a list 
of forty-eight cases there were t^venty-four instances of each sex. Power 
has seen interstitial keratitis improve by the development of menstruation, 
but Mooren ^ has observed the same disease greatly aggravated by the men- 
strual epoch. The possibility that the affection occasionally may arise in 
utero has been raised. R. L. Randolph * reports a congenital clouding of 
the cornea affecting two sisters which he looked upon as a congenital form 
of interstitial keratitis, not differing from the ordinary, or what he called, 
in contradistinction, the post-natal, form of the disease ; and Saltani ^ de- 
scribes diffuse corneal opacity in three brothers and sisters which he con- 
sidered the remnant of an iutra-uterine interstitial keratitis. 

Symptoms. — After a few days of slight ciliary congestion and water- 
ing, a faint cloudiness, usually, but not always, near the centre of the cornea, 
appears. The spots of haze, if carefully examined, will be found to be 
interstitial opacities, — that is, within the structure of the cornea itself, and 
not on either surface. In two or three weeks they spread until the whole 
cornea is invested with a diffuse haziness, veiling or completely hiding the 
iris, except perhaps through a narrow rim at the margin of the cornea. 
The steamy surface has often been compared to ground glass. Careful in- 
spection, however, will reveal that the opacity is not uniform, but contains 
saturated whiter spots scattered through it, or, as Mr. Hutchinson remarks, 
" centres, as it were, of the disease." There are always at this stage ciliary 
congestion, some pain, and dread of light. Blood-vessels derived from the 

1 Transactions of the Ophthalmological Society of the United Kingdom, vcl. viii. 

^ Ophthalmic Keview, 1885, vol. iv. p. 321. 

s Quoted by Power, loc. cit. 

* American .Journal of the Medical Sciences, December, 1888. 

5 Bull. d'Ocul., vol. X., Nos. 10 and 11 ; also Archives of Ophthalmology, December, 

Vol. IV.— 8 



114 AFFECTIONS OF THE EYELIDS, 

ciliary vessels, and formed in tbe layers of the cornea, are thickly set, and 
produce a dull-red color, or the " salmon patch of Hutchinson." These 
patches may be small and crescent-shaped, or large and sector-like. In one 
type, already described under vascular keratitis, the vascularity creeps from 
above and below until the entire cornea is cherry-red, a type seen probably 
when the patient is strumous as well as syphilitic. The subjective symp- 
toms of irritability and photophobia are more pronounced in strumous chil- 
dren. Ulceration rarely occurs. Hutchinson in only one or two cases was 
able to discover ulcers of distinguishable size. Collins ^ saw four instances, 
all of which commenced with opacity of the cornea, followed by intense 
vascularity, which extended over the entire surface except at the central 
part, which ulcerated, and in one of the subjects perforated. Caudron ^ has 
recorded examples presenting the appearance of pus in the layers of the 
cornea ; and I have seen in the Children's Hospital of this city, in the eye 
of a child eight years of age, a dense central opacity with a yellowish 
collection in the anterior chamber below, resembling an hypopyon. 

Iritis and the formation of synechia are not uncommon ; indeed, Hirsch- 
berg {loc. oit.) thinks they are practically always present, and that the fun- 
dus is more frequently involved than is supposed, — sixteen times in his one 
hundred cases. Not only may posterior synechise form, but Schweigger^ 
has reported a case of interstitial keratitis in which, owing to the swelling 
of the iris, punctiform attachments (anterior synechise) formed between it 
and the cornea without any perforation of the latter membrane. Inflam- 
mation of the ciliary region is occasionally encountered ; secondary glau- 
coma and shrinking of the eyeball may follow. 

In the course of time, varying in accordance with the treatment, the 
eye begins to clear, usually from the periphery. Perfect recovery of the 
transparency must be rare, but often the remaining haze is so slight as to 
cause but little interference with vision. In bad cases a dense central 
opacity remains, but even this in time may clear up in a surprising man- 
ner. Years after an attack of interstitial keratitis, minute vessels, nearly 
straight, branching at acute angles and short bends, may be detected in the 
cornea. According to Hirschberg, the vessel-formation never subsides en- 
tirely, and with the aid of a corneal loup he has seen this thirteen years after 
an attack. The presence of these vessels and the deposits in the retina 
after the disease may be utilized for the diagnosis of inherited syphilis. 

The subjects of typical forms of this disease often present a remarkable 
combination of physical defects. The dwarfed stature, the coarse flabby 
skin, the sunken nasal bridge, the scars at the angle of the mouth and the 
alse of the nose, the malformed permanent teeth, in which especially the 
central incisors have vertically notched edges (Hutchinson's teeth), indelibly 



1 Koyal London Hospital Reports, January, 1887 

2 Revue generale d'Oplitalmologie, April, 1889. 
^ Archiv f. Augenheilkunde, xvii. 4, 1887. 



LACHRYMAL APPARATUS, CONJUXCTIVA, AND CORXEA. 115 

stamp the inheritauce of the patient. Baker aud Story {loc. cit.) found this 
character of teeth present thirty-one times among forty-eight cases. The 
presence of deafness, cicatrices in the pharynx, chronic periostitis of the 
tibia, aud indurated post-cervical aud epitrochlear lymphatic glands, still 
further emphasize the syphilitic taint. 

Diagnosis. — A mistake in diagnosis cannot readily occur. The course 
is usually quite typical, and the associated symptoms characteristic. The 
tension of the ball and the age of the patient help to exclude primary glau- 
coma, while the history and character of the inflammation diiferentiate it from 
old corneal maculas and from the diffuse infiltration of the cornea which is 
sometimes seen as the result of injury. The presence of the minute straight 
vessels is always good evidence of former interstitial keratitis. These ves- 
sels must be distinguished from those which remain after pannus : in the 
latter they are more superficial and pass into the anterior conjunctival ves- 
sels, there are well-formed anastomoses, the broader veins are accompanied 
by finer arteries, and there are peculiar ramifications of the smaller deep 
vessels. The vessels seen in corneal scars after ulceration are confined to 
these ; the rest of the cornea is free. 

Prognosis. — The duration of the disease is always lengthy; from six 
to eighteen months are usually consumed in the development of its various 
stages. The second eye is almost certain to be attacked in from a few weeks 
to two months ; in rare instances the interval is many months, or even a 
year, and, according to Hirschberg, may be delayed from five to six years. 
The patient or his friends must be warned of this fact. A return to per- 
fect transparency is unusual ; the vessel-formation in the cornea probably 
never subsides entirely, but even long-continued opacity may often, in the 
course of time, markedly lessen, and reasonable vision eventually be re- 
stored. The occasional onset of deep-seated inflammation in the ciliary re- 
gion, and the fact that, after the cornea has cleared, the ophthalmoscope may 
discover evidences of former choroiditis or of glaucomatous cupping of the 
disk, must not be forgotten in reudering a prognosis. Relapses are frequent, 
and, as Hirschberg has pointed out, occur not always of the corneal disease, 
but in inflammations of the iris and retina. Abadie^ and De Wecker^ 
consider the disease more severe than it was formerly thought to be. 

Treatment. — All irritating applications are harmful. Atropine, to 
maintain mydriasis, prevent iritis, and allay inflammation, is to be system- 
atically employed ; if the irritation is great, this may be cautiously com- 
bined with cocaine. Any high grade of inflammation calls for the frequent 
use of hot fomentations, aud tenderness in the ciliary region will be relieved 
by a leech placed upon the temple. The eyes may be protected from dust 
and light by goggles or a dark shade. The best general medication is a 
long-continued course of mercury. Certainly in children, and probably in 
all instances, the most satisfactory method of administration in the early 



1 Soc. franc;. d'Ophih., 1887. ^ Ibid. 



116 AFFECTIOXS OF THE EYELIDS, 

stages is by inunction, — one drachm of the ointment rubbed into the skin 
once or twice a day, according to the circumstances. It is a good plan to 
order the mercurial ointment put up in oue-drachm masses, thus securing 
the inunction of a definite quantity. The usual precautions in regard to 
changing the spots for the rubbings must be observed. Whenever slight 
tenderness of the gums is apparent, the remedy should be discontinued, and 
the patient put upon a course of iodide of ^Dotassium. During the adminis- 
tration of the inunctions, cod-liver oil may be advantageously exhibited ; 
later, a long-continued course of bichloride of mercury is the most valuable 
remedy, and, as many of the patients are anaemic, this is readily combined 
with tincture of chloride of iron. A suspicion of malaria calls for qui- 
nine and arsenic, and in any event they are useful adjuvants. When all 
irritation has subsided, absorption of the remaining opacity is facilitated by 
the use of a salve of yellow oxide of mercury, together with massage of 
the cornea. Iridectomy, if the tension rises and glaucoma threatens, may 
be followed by excellent results : that it should be employed for new 
pupil when stubborn central opacity remains is manifest. Any. line of tonic 
treatment, and due precaution in regard to nourishing diet, exercise, and 
healthful surroundings, in short, all measures which elevate the standard of 
the sufferer's general health, are indicated. Abadie and others have recom- 
mended that the mercury be given in the form of hypodermic injections. 
A trial of this plan has not caused me to abandon the older methods. 

Keratitis Pu]nxtata. — This affection is almost always secondary to 
disease of the iris, choroid, or vitreous, and is characterized by a precipitate 
of opaque dots, generally arranged in a triangular manner, upon the pos- 
terior elastic lamina of the cornea (Descemet's membrane). The same name 
is also applied by some writers to those cases in which isolated whitish spots 
surrounded by a cloudy area appear in the parenchyma of the cornea. The 
disease is seen in children before puberty, and is probably syphilitic in 
origin. Inflammatory evidences, the appearance in the cornea of the white 
dots, and the later development of iritis with more diffuse corneal infiltra- 
tion, characterize the disease. Iodide of potassium and bichloride of mer- 
cury are the proper internal remedies. A continued atropine mydriasis 
should be maintained ; later, iridectomy may be required to check the iritis,, 
or for optical purposes. 

Malarial Keratitis. — Any form of keratitis may be aggravated and 
sustained by the presence of malaria. The relation of this cachexia to in- 
flammatory diseases of the cornea has been especially studied in this coun- 
try by Kipp^ of Newark. E. van Milligan^ has described an essential 
form of keratitis in association with intermittent fever similar to the kera- 



Transactions of the American Ophthalmological Society, 1889. 
Centralblatt f. prakt. Augenheilkunde, 1888. 



LACHRYMAL APPARATUS, CONJUNCTIVA, AND CORNEA. 117 

titis dendritica of Hock, Griit, and Emmert. This appears as a super- 
ficial erosion of the cornea, with local pain, photophobia, pericorneal injec- 
tion, and anaesthesia, together with the evidence of malaria in the spleen, 
etc. Milligan's cases occurred in adults. In Kipp's cases the disease was 
observed chiefly in persons between twenty and fifty years of age ; five oc- 
curred in persons under five years, and one in a nursing baby whose mother 
had intermittent fever. The treatment of such cases, in addition to local 
sedative measures, resolves itself into the management of the malaria which 
is their cause. i 

Herpes CoRNEiE.^ — In herpes zoster of the first division of the tri- 
facial, the eye may become affected, especially if the eruption occur upon the 
parts supplied by the nasal branch. The pain and swelling of the affected 
area are so great as often to resemble erysipelas, and ulceration of the cornea 
and iritis develop. Herpes zoster ophthalmicus prevails for the most part 
among adults, but, as Horner has pointed out, the cornea may also suffer in 
connection with herpes labialis when this appears in childhood. 

Symptoms. — The disease begins with a series of transparent vesicles 
upon the cornea, mostly near its margin, with pain and marked lachryma- 
tion. After a time the vesicles burst, and an irregular area of corneal 
opacity remains. Iritis may occur. The disease is slow in progress, and, 
after recovery, opacities remain. Horner observed the disorder in con- 
junction with labial herpes associated with pneumonia, bronchitis, and 
catarrhal conditions of the respiratory tract. 

Treatment. — This consists in relieving the general condition, together 
with the local application of atropine and antiseptic washes. 

Conical Cornea (Keratoconus). — This consists in a cone-shaped 
bulging forward of the cornea, and is rarely congenital. It is mostly seen 
in young women, and usually does not develop until after the age of fifteen. 
Exhausting illness and especially chronic dyspepsia have been assigned as 
exciting causes, the immediate cause being a disturbance in the relation of 
the intraocular pressure to the resistance of the cornea. The eye becomes 
myopic and highly astigmatic. Although cylindrical lenses may not avail 
in advanced cases, certainly, as Thomson^ and Wallace^ of this city have 
well shown, in some instances their employment increases markedly the 
visual acuity. If the apex of the cone appears to be thinning, the use of a 
weak solution of sulphate of eserine and of a pressure-bandage is indicated. 
Iridectomy and the substitution for the apex of the cone of a contracting 
cicatrix are the operative measures which have been employed. 



1 This term is often, as Horner observes, incorrectly used as synonymous with phlyc- 
tenular keratitis. 

"^ Transactions of the American Ophthalmological Society, 1874. 
^ University Medical Magazine, January, 1889. 



118 AFFECTIONS OF THE EYELIDS, 

BuPHTHALMOS. — Synonymes. — Hydrophthalmos congenitus, Kerato- 
globus, Megalocornea, Glaucoma congenitum. 

In this rare aifection there is a slow but progressive enlargement of the 
eye in all its diameters ; the cornea is flattened, and the anterior chamber 
much deepened ; the tension is raised. In the course of time the cornea 
may become cloudy, although this participation is not always present. The 
affection appears at birth or shortly afterwards, and its incipient stages 
are believed to be intra-uterine. The precise cause is not accurately deter- 
mined ; it has been ascribed to an intra-uterine irido-keratitis with increased 
intraocular tension, — in other words, a form of congenital glaucoma. In 
megalophthalmic eyes, according to M. Durr,^ the oblique muscles present 
a greater obliquity than is ordinarily the case, and produce a noticeable 
compression upon the emergent veins. The prognosis is unfavorable : the 
aifection usually progresses to blindness. Eserine and iridectomy are 
recommended methods of treatment. 

Aecus Senilis, or a circle of fatty degeneration just within the margin 
of the cornea, is, as its name implies, almost invariably found in old per- 
sons. Occasionally, however, a genuine example of this affection appears 
to have been noted in children. H. F. HanselP reports an instance in a 
mulatto boy three and a half years of age, resembling in all particulars the 
arcus of adult life. Canton'^ doubts whether this has ever been seen at 
birth, and thinks it likely that instances so reported have been due to arci- 
form opacity the result of ulceration. The aifection requires no treatment. 

Tumors of the Coenea. — These are very mre, and include such 
growths as develop from the epithelium, as epithelioma, or invade it by 
extension from neighboring tissues, as sarcgma. Benson ^ has reported an 
instance of fibroma of the cornea in a girl aged nineteen. 

Dermoid tumor occurs as a firm, hemispherical, yellowish-white growth 
lying partly upon the cornea and partly upon the conjunctiva. The apex, 
often paler than the rest of the growth, is covered with short hairs. These, 
however, occasionally grow to an unusual length, as in Wardrop's^ case, 
where they protruded through the fissure of the lids and hung down upon 
the cheeks. If undisturbed, the tumor may slowly enlarge ; and Graefe has 
recorded one instance where the size of a walnut was attained. Bilateral 
dermoids have been recorded, as in Wallenberg's ® patient, a child of eight 
years, the point of origin being the conjunctiva in the neighborhood of the 
external rectus. It is a congenital growth, and is sometimes associated with 

1 Annales d'Oculistique, July and August, 1888. 

^ Medical News, April 4, 1885. 

^ Quoted by Hansell, loc. cit. 

* Ophthalmic Eeview, 1887, p. 5. 

^ Essays on the Morbid Anatomy of the Human Eye, Edinburgh, 1808, 

6 Inaug. Diss., Konigsberg, 1889, Schmidt's Jahrbiicher, No. 10, 1889. 



PLATE I. 

Fig. 14. 




Micro-Photograph from a Section op Dermoid Tumor of the Cornea, showing 
THE General Structure. 



Fig. 15. 




^' 


V 


•i^^ 




f: 


- 




f" 


xv 









Micro-Photograph from the same Section, more highly magnified. 



LACHRYMAL APPARATUS, COXJUXCTIVA, AND CORNEA. 119 

other anomalies of the Hd and eyes. Picque ^ has collected ninety-four cases 
of dermoid tumors of the cornea and conjunctiva, eighty-five of which were 
observed in human eyes. These dermoids have 
been ascribed by Van Duyse to the remains ^ "^ 

of amniotic adhesions ; but Picque, basing his ' ",2-=^— 

view upon the fact that the structure of the ;^^ ^S£^ 

growths very oft^n agrees with that of the lid- 
border, thinks they result from the coalescence 
of the eyelids in such a way that at the mo- 
ment of separation one lid attracts to itself a 
portion of the other. 

Microscopicallv, the growth represents the ^^™'?':l ^"^Tl "1 '^® f°'"®^' 

, ^, ^ (Philadelphia Hospital.) 

structure of the skin and its appendages. The 

presence of striped muscle-nbre and acinous glands analogous to those in the 

conjunctiva has been described in dermoid tumors growing from the caruncle.^ 

Congenital Anomalies of the Cornea. — Microphthalmos is that 
condition in which the entire eye remains in a more or less rudimentary 
state, and in which the cornea is too small in all its diameters. Pure cases 
of microphthalmos, according to Manz, are among the greatest of rarities ; 
usually one or other of the component portions of the globe is wanting. 
Numerous theories have been expressed in regard to the etiology, — retarded 
growth of the cerebellum (Kundrat), incomplete closure of the foetal ocular 
cleft (Arlt), foetal illness in orbita (Wedl and Boch), intra-uterine sclero- 
chorio-retinitis (Deutschmann). This affection has also been ascribed to the 
influence of heredity. 

Megalophthalmos has been described on page 118. 

Sclerophthalmia is that condition in which the opacity of the sclerotic 
encroaches upon the cornea in such a manner that only the central portion 
remains transparent. It is due to an imperfect differentiation of the cornea 
and sclera at an early period of foetal life. 

Congenital opacities of the cornea are seen either in the form of milky 
spots which may clear up in later life, or as dense leucomas. They are due 
either to intra-uterine inflammation or to an arrest of development. 

Congenital staphyloma of the cornea appears in the form of a true 
staphyloma, and is a rare affection. The abnormality depends not so much 
upon a malformation, or an arrest of development, as upon a foetal inflam- 
mation which, according to Pincus,^ takes place in the second half of foetal 
life. Heredity probably plays some role in this and similar affections of 
the cornea. Bernheimer has seen congenital staphyloma of the cornea asso- 
ciated Avith dermoid formation. 

1 Anomalies de Developpement et Maladies congenitales du Globe de I'CEil, Paris, 
1886. 

2 Wallenberg, loc. cit. 

^ Beitrag zur Lehre vom Staphyloma Corneas Congenitum, Inaug. Dissert., Konigs- 
berg, 1887. 



DISEASES OE THE EYE: 

THE ORBIT, SCLEROTIC, IRIS AND CILIARY BODY, VIT- 
REOUS, LEXS, EXTERNAL OCULAR MUSCLES; 
REFRACTION; WOUNDS AND INJURIES; 
SURGICAL OPERATIONS UPON 
THE EYE. 

By CHAELES S. TUENBULL, M.D., 

AXD 

GEOEG-E M. GOULD, 3I.D. 



THE ORBIT. 



Anophthalmus, or Coxgexital Absexce of the Eyeball. — 
Although this and other congenital anomalies of the globe of the eye, con- 
sidered as a whole, may not always be connected with orbital abnormality, 
they are sometimes so related, and may therefore be conveniently classed in 
this place. Collins^ has gathered the details of all the cases of this affec- 
tion that have been published. They number thirty bilateral and twelve 
monolateral instances,^ of which there were post-mortem examinations in 
nine. As to the primary cause, neither hereditary influences nor consan- 
guinity of the parents existed in a large majority of the cases. There was 
a maternal impression of fright in a number of the cases, and Collins is 
inclined to allow this as a possible cause. However well the appendages 
of the globe are developed, no trace of the globe itself is usually to be 
found, and the defect seems due to an early developmental cessation, the 
primary optic vesicle failing to bud from the anterior primary encephalic 
vesicle. Ten cases are reported as dying within two mouths from birth, 
and bodily and mental defects were more or less frequent. 

Cryptophthalmus, a congenital union of the eyelids, usually over 
imperfect eyes. — In this defect^ the developmental failure seems to be 
arrested at the formation of the lens : the lids, conjunctival sacs, etc., are 
wanting or are malformed. 

^ London Ophthalmic Hospital Eeports, vol. xi. p. 429. 

2 Several other case.s have since been reported: see Ann. Univ. 31 ed. Sci., 1889. 
^ Studied by Hocquart, Arch. d'Oph., vol. i. p. 289. 
120 



DISEASES OF THE EYE. 121 
MiCROPHTHALMUS, OR AbXORMAL SmALLXESS OF THE EyEBALL. 

This abnormality is not infrequently coincident with unusual smallness of 
the head, or defective cerebral and mental development, and is still more 
commonly associated with such imperfections as cataract, nystagmus, stra- 
bismus, corneal, retinal, or nerve disease, subnormality of vision, and even 
blindness. Deutschmann thinks the cause of these anomalies is to be 
sought in foetal inflammatory processes ; Hesse ^ inclines to Arlt's theory 
of a non-closure of the optic cleft ; Kundrat supposes a cerebellar failure 
of development ; and Becker concludes that there was a failure of the ecto- 
dermal invagination. It is, of course, only in the case of the cataractous 
complication that any therapeutical or surgical procedure promises to be an 
advantage. When it is certain that a functional retina and nerve exist, the 
cataract should be needled as early as possible, — before vision has been lost 
or deteriorated, and before nystagmus and squint have become fixed habits. 

Cyclopia. — Fusion of the two orbits into a single cavity in the median 
line of the forehead, with misformed and functionless remains of one or 
both globes, is a rare vice of development. 

Congenital Abnormalities of the Orbital Walls. — These are 
iisually the result of a general asymmetry of the head, and may be so ex- 
treme as to interfere with the development of the eye. In some cases the 
fissures are abnormally placed, confluent, or constricted, and cases have been 
reported wherein the optic foramen was wanting. Failure in the lamina 
cribrosa or upper part of the orbital wall may result in a cerebral hernia 
into the orbit, the sac being composed of the dura mater. 

Acquired Anomalies of the Orbit. — These may arise from osteo- 
matous and other tumors, from tuberculous disease, or from hereditary 
syphilis of the walls of the orbit. The symptoms of osteoma will depend 
upon the position of the neoplasm. If it attain a considerable size, the 
globe will be pushed either forward or to one side, and, if the pressure 
upon the globe become so great that the circulation and function of the eye 
are hindered, visual failure consequent upon atrophy will speedily follow. 
This is especially true when the tumor extends towards or about the optic 
foramen. From the uncertainty as to the diagnosis and the impossibility 
of any therapeutic measures except surgical ones, it follows that blindness 
usually precedes enucleation, just as enucleation must precede removal of 
the tumor. 

In reference to orbital tuberculosis, the coexistence of foci of tubercular 
deposits or processes elsewhere should lead to the earliest possible diagnosis 
of the retrobulbar affection. When the diagnosis is certain, no delay must 
be allowed, and complete surgical removal of every infected tissue is neces- 
sary to avoid what is not infrequently a sequel of delay, — thrombo-phlebitis 
of the orbital veins, and meningitis. 

Syphilitic disease of the orbital walls has been rarely observed. The 



' Graefe^s Archiv, Bd. xxxiv. Heft 3. 



122 



DISEASES OF THE EYE. 



vvell-kuown general symptoms of syphilis should, in case of ocular aifections 
of this kind, lead one to the diagnosis. 



Fig. 2. 



Fig. 1 




Antero-Posteeioe Vertical Section 
THROUGH THE GLOBE AND Oebit.— a, 6, Su- 
perior and inferior conjunctival cul-de-sacs ; 

c, adipose and other tissues of the orbit; 

d, tendons of the external ocular muscles. 



Frontal Section of the Eye and Orbit.— a, exter- 
nal rectus muscle; b, internal rectus; c, superior rectus; 
d, inferior rectus ; e, superior oblique ; /, inferior ob- 
lique; g, levator palpebrse; h, supra-orbital nerve; i, 
lachrymal gland; k, infra-orbital nerve; I, temporal 
muscle. 



To aid in a more exact comprehension of the relations of the orbital walls 
and the contents of the orbit, three illustrations are inserted, the first (Fig. 1) 




Schematic Section of the Globe of the Eye. — a, cornea; 6, iris; c, ciliary body;^ 
d, crystalline lens; e, sclerotic; /, choroid; g, retina; h, optic nerve. 

showing a perpendicular median section through the globe and orbit from 
before backward ; the second (Fig. 2), a similar section made laterally ; 
and the third (Fig. 3), a schematic section of the globe of the eye. 



DISEASES OF THE EYE. 123 

Tumors axd Cysts of the Orbit, — These in children are far less 
frequent than in adults, and consist, so far as tumors are concerned, almost 
exclusively of sarcomata. Cases of metastatic myxo-sarcomata and of cere- 
bral sarcomata growing into the orbit have been reported, also echinococcus 
and cysticercus cysts. The symptoms will depend upon the location and 
growth of the tumor. Exophthalmus and papillitis are the more probable 
ones, and, where they are not too deeply located, prompt surgical inter- 
ference may save the eye. 

Vascular Diseases of the Orbit. — These in the young are rare 
affections, and almost without exception secondary to traumatism, to con- 
cussion of the brain, or to wasting diseases. Orbital aneurism following 
some injury will produce pulsating exophthalmus, and ligation of the carotid 
may become necessary. Venous thrombosis with septic infection is rare 
and of difficult diagnosis. The exophthalmus of exophthalmic goitre may 
be classed among vascular affections, but the local abnormality requires no 
attempt at local therapeutics. 

Orbital Cellulitis. — This severe affection may occur in the young 
as a result of traumatism, following surgical operation, secondary to septic 
phlebitis, or accompanying panophthalmitis. There will be exophthalmus, 
inflammatory swelling of the lids, pain, etc. Unless the products of inflam- 
mation find an outlet, the pressure upon the globe may endanger its func- 
tion or existence, so that upon any indication of a pointing of the abscess it 
should be carefully but speedily evacuated. In lancing Tenon's capsule or 
the oedematous lids, caution is requisite not to injure the globe. The eye 
should be kept dressed with hot bichloride dressings, frequently renewed, 
and the patient's general strength supported by the free administration of 
tonics, a liberal diet, etc., while the kidneys, skin, and bowels should be kept 
active. 

DISEASES OE THE SCLEROTIC. 

The only primary or idiopathic disease of the sclerotic is scleritis or 
episcleritis, and this, infrequent in adults, is yet more so in the young. Per- 
haps it is most commonly met with accompanying keratitis scrofulosa (in- 
herited syphilis) with conjunctivitis lymphatica (Arlt), and is often mistaken 
for phlyctenular conjunctivitis. Iritis and cyclitis are rarely, if ever, seen 
in these cases, unless of traumatic origin. Scleritis and episcleritis begin 
with a localized focus of congestion near the corneal margin. The inflam- 
mation is differentiated from conjunctival affections by making traction upon 
the conjunctiva or lid, and the violet-red, inflamed structures are seen to be 
beneath the normal conjunctiva. The affection shows a curious tendency to 
change its location and move circle-wise about the cornea, the former seat 
becoming normal as the advance is made to a new position. There is little 
pain, but tenderness to the touch. The greatest danger consists in the 
liability of implication of other organs, — the cornea, iris, and ciliary body, 
— and to avoid this the treatment should be prompt. It is better to pre- 
vent the irritation arising from the functional activity of the iris and ciliary 



124 



DISEASES OF THE EYE. 



muscle by using a mydriatic solution of atropine, without a bandage. This 
will usually serve to cut short the affection. But it will commonly be found 
that these children have some systemic dyscrasia, and if syphilitic or scrof- 
ulous taint exists, or if there is other evidence of defective nourishment, 
special emphasis should be laid upon the correction of these things. With 
coincident or resultant iritis, cyclitis, or keratitis the same treatment is 
almost entirely directed to the important structures threatened. 

DISEASES OF THE IKIS AND CILIAEY BODY. 

CoLOBOMA OF THE Iris. — Congenital defects of the iris from develop- 
mental failure are occasionally met with, and such gaps or breaks in its 
continuity do not usually interfere with good vision, unless they extensively 
involve the choroid. They are beyond operative treatment. 

Persistence of the Pupillary Membrane, — De Wecker and 
Landolt,^ Collins^ and Wickerkiewicz,^ have described this congenital 
anomaly, consisting of fibrillar bands or filaments stretching across the 

pupillary area and inserted into the 
anterior surface of the iris. It is 
chiefly of importance from the fact 
that it might be mistaken for syne- 
chise or old iritic affection. Vision 
is slightly impaired. An illustration 
of this interesting remnant of foetal 
ocular life is given in the accompany- 
ing cut (Fig. 4). 

Corectopia, or Displacement 
of the Pupil. — In many cases the 
pupil is congenitally misplaced, so 
that it is not accurately behind the 
centre of the cornea nor in front of the lens. In rare instances this ectopia 
is so great as to become a source of imperfect vision and of unsightliness. 
As a consequence of traumatism and of operations upon the cornea, the pupil 
may likewise be drawn to one side, greatly distorted, or even obliterated. 
In such cases an artificial pupil or an optical iridectomy is advisable, though 
the results are often unsatisfactory. 

Iritis and Irido-Cyclitis. — The iris and the ciliary body are in the 
young exceptionally exempt from acute or primary inflammations. Almost 
the only exception to this rule is the rare iritis of hereditary syphilis and 
of tubercle, and in such cases the existence of other symptoms will be suffi- 
ciently pronounced to give the clue for diagnosis. The choroid is almost 
certain to be implicated in the inflammatory process, and the existence of 
the eye itself greatly endangered. The somewhat obscure form of iritis 

1 Traite complet, tome ii. p. 381. 

'•^ Royal London Ophthalmic Hospital Keports, July, 1888. 

^ Graefe's Archiv, Band xxxiv., Abth. 4. 




DISEASES OF THE EYE. 125 

called serous iritis, or irido-choroiditis serosa (the keratitis prsecipitata of 
Arit, and aquo-capsulitis or punctate keratitis of the older writers), is occa- 
sionally observed in the young. There is little or no tendency to plastic ex- 
udation, and the chief signs consist in minute punctate flecks upon Descemet's 
membrane, turbidity of the aqueous, increased tension, impaired vision, pain, 
and a sluggish, somewhat contracted pupil. To these symptoms Horner adds 
hypersemia of the papilla and fulness and tortuosity of the circumpapillary 
retinal veins. The affection is usually a product of some systemic dyscrasia, 
occurring most frequently in girls approaching puberty, in the scrofulous, 
the anpemic, etc. The general indications for treatment will therefore de- 
pend upon counteracting the systemic abnormalism. If the pressure in the 
anterior chamber becomes so great that atropine does not produce mydriasis 
(the pressure preventing its absorption), paracentesis is urgently indicated. 
The incision should be made with a needle, and sudden or extensive drain- 
age carefully avoided. This may be repeated as often as the tension or pain 
again becomes extreme. Moderate catharsis, diuresis, and, in severe cases, 
artificial diaphoresis (by pilocarpine) are advisable. 

Septic or metastatic irido-cyclitis may arise in infants, and has been called 
puerperal panophthalmitis. It is almost absokitely fatal, and is properly to 
be classified as an embolic or suppurative choroiditis. 

Horner observed one case of tuberculosis of the iris in four thousand cases. 

Plastic iritis, common in adults, is of great rarity in children, and, when 
it exists, is secondary to traumatism or affections of the cornea or other 
neighboring tissues. 

As regards the treatment of intis, there are few exceptions to the rule 
that it is of primal importance to prevent adhesions of the iris to the lens- 
capsule, or, if they have already formed, to break them up. For this pur- 
pose atropine-instillatious are demanded. Should these not succeed, or if 
persistent atropinization produce local or general irritation, mercury by the 
mouth or by inunction may be pushed until found useless or no longer 
advisable. We must not neglect to be on the lookout for possible atropine- 
poisoning in certain idiosyncrasies. 

Glaucoma. — This is a disease characterized by abnormal increase of 
intraocular tension or pressure, and, though occurring extremely rarely in 
children, a few cases have been met with, and a mention of the fact may be 
made here. The diagnosis depends principally upon the tactus eruditus, a 
sensation of unusual hardness being imparted when the globe is delicately 
palpated by the fingers. When this excess of tension has reached a con- 
siderable degree, there will be pain of the eyeball, radiating to deeper parts, 
anaesthesia of the cornea, dilatation of the pupil, a shallow anterior chamber, 
etc., and, with the ophthalmoscope, a cupped disk. The etiology of the 
affection is obscure. The treatment consists first in repeated instillations of 
a solution of salicylate of eserine (gr. ^-| ad 5i). When this has been 
proved to give no relief, a broad, large iridectomy should be made at the 
superior part of the iris. 



126 



DISEASES OF THE EYE. 



DISEASES OF THE YITEEOUS. 

Persistent hyaloid artery is almost the only abnormality of the vitreous 
in children, and that needs but a mere mention, since the anomaly admits of 
no treatment. Indeed, in the majority of cases it does not greatly interfere 
with the visual function, and is more an ophthalmological curiosity than 
a disease. Ophthalmoscopically it appears as a translucent mobile fibril 
extending from the central artery of the retina, or from a branch of the same, 
through the vitreous to the posterior capsule of the lens. It is the remnant 
of the artery ^vhich in foetal life nourished the lens and capsule. 

DISEASES OF THE LE^^S. 

The diseases of the crystalline lens consist in defects of form, — colo- 
bomse, etc., — defects of position, — luxation, — and defects of transparency, or 
cataract. The lens, not being nourished by blood, and being without nerves, 
is not subject to true inflammatory action. 

Defects of Form. — These are, of course, congenital, and, as the re- 
sultant impairment of vision is usually slight, and the condition itself 
is not remediable by operation, except by extraction of the lens, it follows 
that but a j^assing mention is required. Several cases of asymmetry of the 
lens, of coloboma, etc., have been reported, caused by develojamental defect 
either of the ligament of the lens or of the lens itself. The condition 
called anterior lenticonus or crystalloconus consists in a (transparent) pyram- 
idal exaggeration of curvature of the anterior portion of the lens, the 
anterior chamber thus being more shallow and partially filled by the lens. 
The obverse of this condition may sometimes exist, and is called posterior 
lenticonus. 

Defects of Positiox. — The lens may be congenitally displaced, and 
this class of positional defects is called ectopia lentis. It is usually sym- 
metrical, and a noteworthy peculiarity is that the displacement is generally 
upward, or upward and inward. It is more rarely laterally displaced, 
and never directly downward. An illustration is appended of a case of 

Fig. 5. 





symmetrical ectopia lentis that was recorded some years ago.^ (Fig. 5.) 
The direct cause of the abnormality is doubtless some imperfection in the 
insertion or inequality of the length of the fibres of the lenticular liga- 



1 Trans. Amer. Ophthalmol. Soc, reported by Dr. W. S. Little, 1883. 



DISEASES OF THE EYE. 127 

ment or zonule of Ziun. Indirectly the influence of heredity is clearly 
manifest as an etiological factor. In a large majority of the cases the 
lens remains transparent or semi-transparent. If the ectopia is consid- 
erable in extent, the iris may be distinctly seen to be pushed forward by 
the lens-edge, and that part of the iris that is unsupported by the lens ex- 
hibits a tremulousness with jar or motion of the globe. The disturbance 
of vision will depend entirely upon the extent and the kind of the mal- 
position. Visual acuity will usually be improved by high refractive lenses, 
concave if the crystalline lens be used as a part of the dioptric system, con- 
vex if the functional part of the system be aphakial. All the cases we have 
seen have been practically aphakial, the lenses being too far removed from 
the axis of vision to be useful in seeing. Sometimes the lens is not station- 
ary, but, owing to a lax zonule, moves with or follows motions of the eye- 
ball or head. Cases have been reported wherein the lens still in its capsule 
has passed through the pupil. In such instances the operation of extraction 
is clearly indicated. An abnormal position of the pupil may sometimes exist, 
and create much the same result as an abnormal position of the lens. This 
pupillary anomaly may be congenital or traumatic, — ectopia pujnllmis con- 
genita seu traumatica, — and the treatment by operation, if any be advisable, 
will depend upon many varying circumstances. 

Acquired abnormalism of position of the lens is usually caused by blows, 
concussion, or injuries of the eyeball or head, and is called luxation or dis- 
location} When the displacement is only slight, it is called subluxation. 
The immediate possibility of luxation depends upon a rupture of the lens- 
ligament or capsule, so that the lens usually becomes cataractous, either 
slowly or quickly, from defective nutrition, or from the admission of the 
aqueous or vitreous humor to its substance, causing molecular and chemical 
changes that destroy transparency. When the dislocated lens is in the 
vitreous chamber, its extraction becomes impossible. In such cases, acting, 
as it does, as a foreign body, the accident may be followed by symptoms of 
irritation and glaucoma, that may necessitate the enucleation of the globe. 
AVhere the luxation is into the anterior chamber, the prevention of such 
symptoms by means of a prompt extraction is strongly indicated. In this 
position, or when but partially so misplaced and held in position by the iris, 
the abnormal position of the lens, if still transparent, may be diagnosticated 
by the aid of the ophthalmoscopic mirror and from the peculiar position or 
configuration of the iris. When the lens has become cataractous, its posi- 
tion is easily recognized. In this connection consult also the section on 
wounds and injuries of the eye, also that on traumatic cataract, and on 
extraction of cataract. 

Defects of Transparency, — Cataract. — Cataract may be either 
congenital or acquired ; partial (the entire lens not affected) or complete ; 

1 It hardly needs mention that the lens may also be dislocated by intraocular growths 
pushing the lens out of position or rupturing its ligament, or by such changes in the globe 
as staphyloma, retro-ocular tumor, buphthalmos, etc., that also rupture the zonula. 



128 DISEASES OF THE EYE. 

hard or soft ; capsular (the capsule deficient only in transparency) or len- 
ticular; central or peripheral; anterior or posterior; traumatic or patho- 
logical, etc. 

The diagnosis of cataract is a simple and easy procedure, effected by 
the aid of reflected and of transmitted light. The pupil should be di- 
lated by a drop or two of cocaine solution (gr. vi ad si) instilled ten min- 
utes prior to the examination, whereby a larger part of the lens is brought 
into view. By placing the patient so that the source of light is behind and 
at one side of the head, the light is reflected into the pupil by a twelve-inch- 
focus ophthalmoscopic mirror; through a central perforation of Mhich the eye 
is observed. If in place of the usual reddish glow of the fundus-reflection 
the entire pupillary area is dark or neutral-colored, we conclude — the cornea 
and remaining ocular media being supposed to be clear — that complete cata- 
ract is present. If the crimson fundus-reflex is interrupted by dark spots, 
striae, or breaks, a partial cataract is probably to be inferred. Turning the 
patient so that the light falls a little obliquely into the pupil whilst our own 
view is more or less direct, and concentrating the illuminating rays by 
means of a two- or three-inch biconvex lens, we can readily verify the 
diagnosis. Instead of dark or negative spots as before, we shall now see, 
by the light reflected from the cataract, light-colored or porcelain-like 
images of the opacity, whilst the transparent portions of the lens appear 
dark or invisible. By varying the position and focus of the illumina- 
tion we can judge of the nature, position, and extent of the opacity. The 
magnification of the image by a second convex lens may also be found an 
advantage. 

Varieties of Congenital Cataract. — A primary diagnostic dis- 
tinction between congenital cataracts consists in determining if the opacity 
be complete or partial. 

Complete Congenital Cataract is comparatively rare, and not sel- 
dom accompanied by microphthalmus or by other bodily or mental defect. 
The condition itself is an evidence of developmental failure, is binocular, and 
nystagmus is almost certain to follow sooner or later. As seen by reflected 
light, the lens appears of a " milky" or opaque-white color. At an early 
age we cannot always be certain to what extent the retina and nerve may 
be functional ; but if there exists any sign of light-perception, such as that 
shown in following with the eyes a bright light, or if there are indications 
of irritation from sudden exposure to such a light, then the plain duty is to 
proceed with the needle-operation as early as possible. By so doing the 
development of nystagmus may be prevented or checked, and the possible 
decay of the deep-seated visual organs, with amblyopia, obviated by bringing 
them into their normal usage. 

Of Incomplete or Partial Congenital Cataract the principal 
varieties are the central, the lamellar, the stellate, the punctate, the axial, and 
the anterior and posterior polar. 

In congenital central catarcLct we find a white opacity occupying the 



DISEASES OF THE EYE. 129 

ceutral part of the lens, the rest of the body being normally transparent. 
The visnal acuity is better than would be supposed. The origin of the 
defect Mas in some nutritional failure or abnormalism of development in 
the sixth or seventh week of intra-uterine life, when the nucleus of the lens 
was in process of formation. Other ocular defects, as microphthalmus, 
capsular opacities, etc., may also be present. If the opacity be of consid- 
erable size and interfere with vision very greatly, or if nystagmus be 
established or even threatened, either an optical iridectomy or the needle- 
operation should be advised at once. 

Lamellar or zonular cataract probably arises in the same way as the 
central variety, but at a later period of foetal life. The lens, as is well 
known, is composed of strata or layers, sometimes likened to the layers of 
an onion. Some developmental or trophic disorder of intra-uterine life 
intervening at the period of formation of a layer renders it translucent or 
opaque either in part or entirely. The defect is, therefore, of both eyes. By 
attentive. observation the transparent nucleus and the transparent external 
layers may be distinguished from the stratum of cloudy tissue. If for any 
general reason operative measures may not be carried out at once, continu- 
ous artificial mydriasis may be temporarily useful in giving better vision or 
in preventing nystagmus. But this, for obvious reasons, is objectionable for 
any great length of time, and, supposing that vision is decidedly subnormal, 
it is advisable to operate as soon as possible, for reasons already given. If 
the opacity be limited in extent and an artificial pupil promise to give a 
clear space for the light to enter, an optical iridectomy is to be preferred to 
the needle-operation, since in the latter case the power of accommodation is 
destroyed and the patient henceforth becomes the slave of two pairs of spec- 
tacles. But if an iridectomy promise or give no satisfactory result the lens 
must be broken up and given over to the process of absorption. In older 
children, when the lens-substance has attained a considerable degree of con- 
sistency or hardness, it has been proposed, after breaking up the lens, and 
after the resultant softening and partial liquefaction have taken place, to 
extract the lens-matter by a suction-operation, thus obviating the delay and 
possible clanger of the absorption-process. 

The varieties of congenital partial cataract denominated stellate, punc- 
tate, and axial indicate peculiarities in the position or form of the opacity. 
The stellate opacity consists of a star-like figure occupying the anterior por- 
tion of the lens-substance. In the punctate the opacities are small, and 
scattered like dots throughout the lens. In axial or fusiform cataract the 
axis or region of the antero-posterior diameter of the lens is occupied by a 
cloudiness or opacity that interferes with vision in proportion to its equa- 
torial extension or the degree of opacification of the affected tissues. As 
regards the advisability of operative measures, the indications already speci- 
fied obtain also in these cases. 

Anterior capsular cataract is also called anterior polar and pyramidal 
cataract. The opacity is at the anterior pole, and is composed of a hyper- 
■ Vol. I v.— 9 



130 diseasEkS of the eye. 

plasia of the capsular epithelium, which is covered by the capsule, the lens 
itself remaining normally transparent. The defect may be limited in area, 
— that is, not extending far towards the equator of the lens ; and this is the 
more usual form. It may also be even with the rest of the capsule, ele- 
vated, or extending forward from it. In one case, a child of ten years, 
that came under our observation, the pyramid extended forward like a 
glistening white cone through the pupil and anterior chamber, the needle- 
like point seeming almost to touch Descemet's membrane, and the contracted 
iris apparently hugging the base of the pyramid. 

The etiology of this form of cataract is peculiar, and is probably to be 
explained in this way. It is known that the condition may arise after birth 
from the contact of the anterior surface of the normal lens with an inflamed 
cornea, either perforated or not. The same factors are supposed to operate 
in intra-uterine life. The fact that after birth no defect of the cornea is to 
be found does not seem to negative the supposition. Whether the abnor- 
mal contact of the two surfaces be brought about by the emptying of the 
anterior chamber succeeding ulcerous perforation of the cornea, or by tem- 
porary shallowness of that cavity, or by abnormal pressure either in front 
or from behind, the essential mechanism remains the same: the corneal 
inflammatory product passing through the capsule sets up a hyperplasia of 
the internal epithelium, ^vhich results in the capsular opacity, whether the 
latter be pyramidal or simply leave the normal contour unchanged. The 
deepening of the anterior chamber by re-formation of the aqueous, or the 
removal of pressure, etc., again pushes the lens back to its normal position, 
but carries with it the lasting spot or cone of opaque tissue. 

The treatment is, of course, operative, and if, as is usual, the opacity is 
limited to the central pupillary area, an optical iridectomy should be efl^ected 
at an early date. The position of the iridectomy should be in the superior 
segment of the iris and slightly to the nasal side, because in this position the 
upper lid covers the large peripheral part of the opening and leaves the 
more central aperture for visual purposes. The iridectomy should be as 
small as possible in all such cases. In this manner the function of accom- 
modation is preserved. But if this position is covered by a segment of 
opaque corneal tissue, another must be chosen. It may also rarely happen 
that the capsular opacity extends so far towards the equator of the lens 
(shown by extreme mydriasis) that no good could come from an iridectomy. 
In such cases the lens must be extracted by needling and absorption. 

Congenital Posterior Polar Cataract. — Sometimes a dense white 
opacity is found at the posterior pole of the lens, limited in area, and in 
appearance like that just described, but pointing into the vitreous chamber. 
Moreover, like the anterior variety, it is confined to the capsular tissue, and 
the lens is not implicated. Its etiology, however, is very different, since it 
consists, anatomically, of the remains of the vascular structures and connec- 
tions with the foetal hyaloid artery, that have not atrophied or become 
transparent, owing to some disturbance of the normal development. The 



DISEASES OF THE EYE. 131 

visual disturbance is in this defect not generally considerable, and will 
seldom require operative interference. 

One form of congenital membranous cataract not yet described is seen 
in poorly-developed eyes : in cases where one eye is microphthalmic we 
often find a tough membrane like a collapsed lens-capsule without any 
contained lens-substance occupying the position of the lens, and, although 
we have what we consider good light-perception, operative interference 
yields no satisfactory results. The membrane has no elasticity, and tears 
but does not gape. Mydriatics have but little effect, the irides seeming to 
be undeveloped, and we are apt to poison our little patients before we 
secure much, if any, effect. Such cases recjuire the entire removal of a 
piece of the tough membrane before a useful pupil is secured. Here, then, 
our prognosis must be guarded, for after having secured an excellent pupil 
the retina may be defective in development. The teeth of such children 
are frequently ill developed, few, and shark-like, but in no way like syphi- 
litic teeth. Several operations may follow, and an immense amount of time 
and patience be sacrificed for little if any result, and prove a bitter disap- 
pointment both to operator and to parents. 

Varieties of Acquired Cataract. — As in congenital cataract, so 
also in the acquired, the most marked distinction lies between the total or 
complete and the partial or incomplete. In the first class we have to consider 
two principal varieties, — the soft, including the fluid or "milky," the Mor- 
gagnian, and the membranaceous ; and the hard, similar in nature to senile 
cataract. Of acquired partial cataract the chief varieties are the lamellar, 
the anterior polar, and the posterior polar. Traumatic cataract may be 
reckoned A^'ith total cataracts, but, owing to the complications of the case, it 
is desirable to classify it alone. 

Soft Acquired Total Cataract, — In these cases the appearance of 
the lens, as well as its consistency, may vary within wide limits. The lens 
may be of a uniform opaque white, or present a delicate striation at the 
anterior pole ; it may look like milk slightly tinged with a blue cast, 
and be evidently very fluid in consistency, — called caiaracta lactea ; or it 
may consist of a more solid nucleus floating in a liquefied cortical mass 
{Morgagnian) ; or, lastly, it may give evidences of a shrunken aud folded 
lens-capsule (^memhranacea). JSTutritional disturbance undoubtedly plays 
the chief role in the production of soft cataract. Any constitutional dis- 
turbance or affection, anaemia, wasting or infectious diseases, cardiac disease, 
etc., may, by depriving the lens of normal quantity or quality of nourish- 
ment, superinduce opacification of its substance. Heredity has also been 
found to exercise a powerful influence. The direct mechanism of its pro- 
duction consists in the superabundant imbibition or collection of fluid within 
the capsular cavity or among the lenticular fibres. With a functional 
retina and good general health, discission of soft cataract should be under- 
taken as early in life as possible. 

Hard Acquired Total Cataract. — It is often difficult to decide in 



132 DISEASES OF THE EYE. 

the case of the young whether cataract be hard or soft. The differential 
diagnosis is important only in reference to the choice of the method of 
extraction. The large majority of all cataracts in the young are soft, and 
usually there is a milk-white and as it were swollen appearance of the lens. 
Occasionally, and especially, it is believed, in disease of the vessels, par- 
ticularly of the carotid and its branches, cataract in the young approaches 
the hardness of the senile variety. In such a case it should be extracted in 
the same manner as acquired senile cataract. 

Traumatic Cataract. — Any injury, whether by direct penetration 
of a foreign substance or by indirect concussion, that breaks or ruptures 
the capsule of the lens and permits the ingress of the extra-capsular fluids 
of the eye, will produce cataract. (Occasional cases have been reported in 
which a small penetrating body has produced only a limited and as it were 
encysted area of opacification, leaving the rest of the lens permanently 
transparent.) With the entrance of the external fluid the lens-fibres swell 
and break down, until finally the entire body of the lens has been liquefied 
and carried oif by the excretory channels exactly the same as after the dis- 
cission operation. During this absorption-process the eye should be kept 
at rest by paralyzing the accommodation with atropine, whereby, also, the 
iris will more certainly be kept free from entanglements with the capsular 
or cortical remains. It is possible that a portion may resist the solvent 
action of the aqueous and require needling. Wliile the lens-matter is 
swelling, symptoms of increased tension of the eyeball must be watched for 
and proceeded against as in glaucoma. We must also see that no scraps of 
lens-substance fall against and adhere to Descemet's membrane, thus causing 
a large central opacity. Rest for a few days in bed after each needling is 
advisable in the majority of cases. 

Acquired Lamellar Cataract. — This variety is also called zonular 
or perinuclear cataract, and is the most frequent of acquired types. It 
arises in precisely the same Avay as the congenital. During youth new lens- 
layers are being formed, and systemic nutritional failure or abnormalism 
during the formation of a lamina results in its partial or complete opacifi- 
cation. Subsequent strata formed during better health are again normally 
transparent, so that if the defective layer is not so opaque as to prevent 
observation of parts beyond it, we may with widened pupil trace the double 
layer of semi-transparent fibres enclosing a transparent nucleus and sur- 
rounded by more external transparent strata. The greater number of these 
cases may be traced to rachitis. In one hundred and eighty-nine cases 
Von Arx found that over eighty per cent, showed signs or gave histories 
of this affection. In the greater number of instances the coexistence of 
rachitic teeth or cranial asymmetry will point out the general causal nexus. 
Nystagmus and strabismus are not frequent, but are sometimes complicating 
results. The advisability of operative measures, and the choice of opera- 
tion to be carried out, depend upon the extent of visual defect. If not 
more than one-half the normal, and particularly if the defect be binocular, 



DISEASES OF THE EYE. 133 

it will be advisable to operate if we are convinced that the defective vision 
is entirely due to the cataract. Shoidd mydriasis expose a clear lens-space 
at the superior or inferior and nasal segment of the lens, an iridectomy 
should be done at this place. But when no such clear space exists, or when 
the opacity is extensive and extreme, extraction of the entire lens is seldom 
done, discission usually being the preferable method. 

Posterior Polar Cataract, — The acquired type of posterior polar 
cataract differs from the congenital in etiology and in the tissue affected. 
It will be remembered that in the congenital type only the capsule is 
affected, the lens-substance remaining clear. In the acquired variety the 
posterior layers of the lenticular fibres are diseased, the capsule preserving 
its normal clearness. From this fact the latter class is sometimes designated 
as true, and the congenital as spurious, or false, posterior polar cataract. 
Acquired or true posterior polar cataract is secondary to chronic choroidal 
disease, hemorrhage into the vitreous, and other affections of the vitreous. 
Retinitis pigmentosa is in its later stages very apt to be associated with this 
type of cataract. The prognosis is grave, and operation, either from its 
uselessness or from its danger (the eye being usually otherwise seriously 
diseased), is generally inadvisable. 

Acquired Anterior Polar or Capsular Cataract. — The opacity 
is limited to the capsule, and consists of a proliferation or hyperplasia of 
the capsular epithelium, caused by the absorbed products of a perforating 
corneal ulceration. It is not thought that actual contact of the lens-capsule 
with the posterior surface of the cornea is always necessary, though this is 
the most common origin. A perforating ulcer makes an outlet for the 
aqueous fluid ; the anterior chamber is thereby evacuated and the lens 
pushed forward against Descemet's membrane, where it comes in contact 
with the toxic matter of the ulcer, and this being absorbed by the capsule 
induces the opacification. With the closure of the ulcer, and re-formation 
of the aqueous humor, the lenticular system is again pushed back to its 
normal position. The cataract being usually limited in superficial area 
requires only a small optical iridectomy at the superior and slightly inner 
aspect of the iris, by which nearly normal vision will be preserved and the 
accommodative function retained. 

DISEASES OF THE EXTERNAL OCULAR MUSCLES. 

The difficulties and perplexities experienced in endeavoring to arrive 
at an understanding of the abnormalities of the ocular muscles arise from 
three principal sources. In the first place, the disturbances are exceedingly 
complex in origin and kind ; then, they are in many directions entirely in- 
volved in mystery, and extensive and painstaking research is required for 
their thorough comprehension ; and lastly, due in great part to our igno- 
rance of the real nature and origin of the pathologic processes, there is an 
unfortunate difference of opinion among writers upon a majority of the 
subjects connected with the study. Add to all this a nomenclature that is 



134 DISEASES OF THE EYE. 

often misleading, nearly always illogical and inexpressive, and always un- 
scientific!, and we have a consensus of difficulties encountered immediately 
on entering upon the subject. In a work of the present kind, however, 
designed not for ophthalmic specialists, we may ignore the more recondite 
and exceptional phases or aspects, and point out the simpler and more 
common examples of disease which the general practitioner will encounter. 
These may conveniently be grouped under four heads, — spasms, paralyses, 
strabismus, and insufficiency ; though the last two names are in many 
respects highly objectionable terms. 

Spasms op the Ocular Muscles. — Like other muscles of the body, 
the external muscles of the eye may be seized with either clonic or tonic 
spasmodic activity. The only example of clonic spasm that we need to con- 
sider is the mysterious and chronic form called nystagmus, consisting in, or 
rather evidenced by, continuous pendulum-like, oscillatory, or tremulous 
motions of the eyeball. Both eyes are affected, and the movements may be 
of all degrees of rapidity, and may be from side to side, — horizontal nystag- 
mus, — rotatory, vertical, etc. The affection may arise from visual defect of 
many kinds, whether caused by corneal disease or damage, by cataract, or 
by affections of the deeper structures ; or it may be produced by cerebral 
disease of any kind that interferes with the normal function of the centres. 
It is not infrequently associated with developmental defects and anomalies 
of the brain and mental faculties. In so far as nystagmus is dependent 
upon peripheral ocular defects that are remediable, — e.g., in cataract, — 
prompt action should at once be taken to give the patient the best vision 
possible before the visual function has been irreparably damaged and before 
the nystagmus has become too firm a habit. When dependent upon chronic 
cerebral or spinal disease, as in hydrocephalus, meningitis, neoplasms, heredi- 
tary ataxia, etc., the prognosis and treatment are usually hopeless. 

There may also be noted a temporary form of clonic spasm due to acute 
nervous or cerebral disease, as in epileptic attacks, apoplexy, etc. 

Tonic spasm of single muscles of an eye has been observed as a reflex 
from local irritation either of the eye or of adjacent parts, and in acute 
localized cerebral disorders. Spasm of the corresponding muscles of the 
two eyes is called conjugate deviation, and is an evidence of central disease. 
— tumors, apoplexy, meningitis, syphilis, traumatism, hysteria, etc. The 
lateral muscles are those usually affected, the eyes turned either to the right 
or to the left. Sometimes the superior recti are seized and the eyes are 
rotated upward. The cerebral lesion may be either in the cortex or in the 
pons, or in the internal capsule. The direction, right or left, towards which 
the eyes are turned in spasm may indicate the location of the cerebral lesion. 
In spasm the eyes, as it has been expressed, look away from the lesion, in 
paralysis they look towards it. Spasm of the orbicularis is called blepharo- 
spasm, and is usually of reflex origin, especially from astigmatism. 

Paralysis op the Motor Muscles op the Eye. — It may be 
safely said that few affections or none offer the physician more recondite 



DISEASES OF THE EYE. 135 

problems and require more skill and knowledge in diagnosis than those per- 
taining to the etiology and location of the lesions causing the paralyses of 
the various ocular muscles. It is, for example, with our present knowledge, 
often quite impossible to decide whether the lesion is focal or peripheral, 
temporary or permanent, direct or indirect, etc., and whether therapeutic or 
operative treatment is the more advisable. 

Paralysis of the external rectus is the most frequent of single-muscle 
paralyses, due, as Gowers points out, to the long course of the sixth nerve 
over the pons, which renders it peculiarly subject to accidents of pressure. 
The paralyses may therefore be upon one or upou both sides. The function 
of the external rectus is to rotate the eye outward. If the paralysis be 
complete, and not, as sometimes happens, partial, the diagnosis is easily 
made : the eye cannot be rotated outward past the median line. If the 
paralysis be recent, diplopia will be complained of, the distance of the 
images apart increasing the farther the object fixed is carried towards the 
side of the paralyzed muscle. The object being held towards the affected 
muscles and above a horizontal line, the image of the unsound eye is seen 
as if directed away or inclined from that of the sound eye, whilst below 
a horizontal line the false image is inclined towards the other. This is 
caused by the torsional action of the oblique muscles. Coupled with paral- 
ysis of the opposite side of the body, paralysis of the external rectus 
almost certainly points to a hemorrhage or other lesion of the pons. 

The superior oblique is the only remaining muscle whose supply is the 
sole function of a single cranial nerve, — the fourth. Paralysis of this 
muscle is not of great clinical importance, and may exist without complaint. 
It is chiefly evidenced by interference with motion downward when the 
globe is at the same time turned to the nasal side. 

Paralysis of the third nerve may be partial or complete. If complete it 
is called ophthalmoplegia externa, and, unless plainly orbital in origin, points 
to cerebral basal or crus lesions. This nerve, as is well known, supplies all 
the remaining muscles of the eye except the external rectus and superior ob- 
lique. Therefore, when completely paralyzed, we have a striking symptom- 
complex, consisting of complete ptosis, immobility of the globe inward, 
upward, and downward, stabile mydriasis, and paralyzed accommodation. 
Paralyses of individual branches of the third nerve supplying separate mus- 
cles are comparatively easy of diagnosis. Paralysis of the inferior oblique 
alone is rare and unimportant. In paralysis of the superior rectus, motion 
upward is impaired ; in that of the inferior rectus, the corresponding motion 
downward ; in that of the internal rectus, the internal rotation is defective. 
In all such cases, if acute, there will be diplopia corresponding to each, 
with increase of the distance between the images as the object is moved 
towards the side of the paralyzed muscle, characteristic inclinations of the 
images, etc. In determining the seat of the lesion we have to consider the 
history, the coincident affections or paralyses of other muscles, including 
those of the face and the whole body, the completeness and duration of the 



136 DISEASES OF THE EYE. 

paralysis of the affected muscles, the existence of other diseases, as tubercle, 
syphilis, tumor, etc. The evident existence of orbital disease, the preceding 
history of exposure to severe cold or of orbital injiuy, the history of a 
forceps-delivery of the child, and other considerations of a like nature, may 
at once show the lesion to be peripheral. Other symptoms of cerebral 
or basal disease serve to locate the lesion beyond the orbit. The thera- 
peutic measure to be adopted will of course depend upon the diagnosis and 
location of the lesion. Locally three plans of treatment are offered, — the 
electrical, the orthopaedic, and the operative. Galvanization or faradization 
of the affected muscles has in some instances seemed to do good. The same 
may be said of the plan of passive exercise by seizing the conjunctiva at 
the corneal border with the fixation forceps and rotating it in the direction 
of the weakened muscle. Exercise with prisms, the stereoscope, or atropine 
may prove beneficial. Operations are advisable only when other means 
have failed and when a year or more has elapsed without improvement. 
Then tenotomy of the antagonistic muscle, or tenotomy with advancement 
of the paralyzed one, may be undertaken. 

Steabismus, — Squint or " Ceoss-Eye." — This term properly denotes 
a symptom, and, in fact, strabismus is a symptom of paralysis of the ocular 
muscles, of tonic spasm, etc. Some authors make the word cover cases of 
insufficiency. We shall use it only to express the fact that in non-paralytic 
cases when observing an object with both eyes uncovered, the visual axes 
do not cross upon the object. Instead of the term latent strabismus, often 
met with, the word insufficiency may be taken to denote those cases in which 
the visual axes do meet at the object, but only by a strain or an excess of 
contraction or innervation upon the part of certain muscles of one or both 
eyes. If the visual axis is displaced to the nasal side, it is called convergent 
strabismus : if to the temporal side, divergent. The rare conditions in which 
the visual line is abnormally dii^ected upward or downward are called re- 
spectively sursum vergens and deorsum vergens. If the strabismus is of 
one eye, it is called monocular or mouolateral ; if of both eyes, binocular or 
bilateral. If one eye always deviates, it is called persistent ; if either eye 
successively, alternating. Sometimes the deviation only takes place at more 
or less regular periods of time, and it is then called periodic. In extreme 
degrees the fact of deviation is plainly evident, but in lesser degrees it may 
be shown by directing the patient's gaze at an object and alternately cover- 
ing and exposing first one and then the other eye. When the deviating eye 
is forced to fix upon the object by covering the sound eye, the motion of the 
globe becomes easily recognized. The amount of deviation may be meas- 
ured by the strabometer or the perimeter. When the deviating eye follows 
the other in its movements, it is called concomitant strabismus, in contradis- 
tinction to paralytic strabismus, in which the motion of one eye is abso- 
lutely limited in certain directions. The deviation of the squinting eye 
is called the primary deviation. If in a given position the squinting eye 
be forced to fix the object by covering the sound eye, it will be found that 



DISEASES OF THE EYE. 137 

the sound covered eye is now squinting. This is called the secondary de- 
viation, and is due to the fact that an excess of innervation is required in the 
acting muscle of the squinting (though temporarily fixing) eye, and the 
same excess is also supplied the sound covered eye, because both are domi- 
nated by the same centre. Concerning the origin of strabismus and of the 
amblyopia of the squinting eye, there is at present much difference of 
opinion. According to the view of Donders, convergent squint arises 
from the excess of accommodative action in hyperopia, convergence and 
accommodation being always associated actions. Schweigger, on the other 
hand, explains the defect by the natural preponderance of the interni over 
the externi. A third view, but one that, so far as hyperopia is con- 
cerned, is in fact but a logical extension of that of Donders, consists in what 
has been called the innervation theory, advanced by Grut, according to 
which not the muscles but their innervation is made to account for the stra- 
bismus, whether convergent or divergent, and whether associated with hy- 
peropia, emmetropia, or myopia. The question as to whether the amblyopia 
of the squinting eye is a result or a cause of the strabismus is also a dis- 
puted one. The probability is that it is both, the one aiding and exagger- 
ating the other. Concerning this vexed question a parenthetical remark 
may be interposed that, according to the theory of one of the writers,^ the 
long-continued existence of ametropia by supplying the macula with an un- 
physiological and irritating stimulus itself produces a chronic form of 
macular choroido-retinitis (" central choroiditis") or pigmentary degenera- 
tion and amblyopia, regardless of whether strabismus exists or not, but cer- 
tainly increased by insufficiency. If found true, this theory will account 
for many cases of amblyopia heretofore considered as the result of disuse 
(amblyopia ex anopsia). 

The following facts therefore stand out clear and undisputed : that 
most cases of convergent strabismus are associated with hyperopia, or 
hyperopic astigmatism, and most cases of divergence with myopic defects, 
and that the most defective eye ametropically is usually the squinting eye. 

When a patient with recent paralysis of the external oblique comes for 
treatment, the first complaint is naturally of diplopia. But in cases of con- 
comitant strabismus there is no such complaint, though the two images are 
formed upon non-identical points of the two retinae. How is it that, as is 
demonstrably the case, the patient sees with the deviating eye and yet does 
not see double? One explanation is that the mind suppresses the image of 
the squinting eye, a fact illustrated by the microscopist or ophthalmologist, 
who keeps both eyes open while using his instrument. Another explana- 
tion is also given, that by long habit the mental projection of the image of 
the deviating eye is such that it corresponds to the true position of the 
object. Unconsciously the mind makes proper allowance for the malplaced 
retinal image. 



1 See Archives of Ophthalmology, vol. xix. No. 1, 1890. 



138 DISEASES OF THE EYE. 

In tlie treatment of strabismus the first and most important proceeding 
is to correct the ametropia and thus establish the normal relationship be- 
tween accommodation and convergence or divergence. It has been cus- 
tomary to say that this is of little avail, but it is our opinion that this 
latter opinion is not always to be justified, and because of these reasons : 
1. That an accurate correction of the ametropia has not been ordered. 
Reliance has been placed upon the fact that some physician has ordered 
glasses, probably without the use of a mydriatic and by ophthalmoscopic 
examination alone, — in which case no reliance whatever is to be placed upon 
the accuracy of the so-called refraction, regardless of what the skill of the 
adviser may be. 2. Sufficient time has not been given the muscles to 
reassume a condition of equipoise or co-ordination. 3. The weaker muscle 
has not been aided and partially relieved of its strain by a partially-correct- 
ing prism combined with the spectacles. By carrying out these measures we 
can bear witness to the relief of strabismus, in many cases of quite decided 
long standing and convergence. It hardly needs to be said that in the most 
pronounced cases, and especially in older children, only operative measures, 
as a rule, promise success. The cases in which the spectacles do succeed in 
keeping the visual axis fixed illustrate and prove the innervation theory of 
the origin of strabismus negatively as well as positively, since, at least for a 
long time after beginning to wear them, disuse is at once followed by a 
resumption of the original squinting position. The eye having the greater 
total lateral motility is the squinting eye, whether the squint be convergent, 
divergent, or alternating ; and this eye is also the more amblyopic of the 
two. 

It is simply a necessary corollary of what has been said that the earlier 
in life a tendency to squint is arrested by the '' atropine-treatment," or by 
the spectacle-correction of the coincident ametropia, the more promising the 
result and the more certain that the abnormalisms of amblyopia and squint 
will not become fixed. The question at once arises, what shall be done 
with children too young to wear glasses? If the strabismus is convergent, 
stop all studies and near work. If the convergence still continue, institute 
the atropine-treatment, — i.e., paralyze the accommodation of the non-squint- 
ing eye by a weekly or bi-weekly instillation of a strong solution of atropine, 
and thus force the squinting eye to assume a permanent normal position 
until glasses can be worn. It may be added that, if the spectacles be sub- 
stantial and fitted with judgment and care, children may safely wear them 
at a much younger age than is commonly supposed. It is not unsafe to pre- 
scribe spectacles for a child of five to seven years if the optician and mother 
(or nurse) are properly instructed and do their respective duties. Prior to 
this age, if the atropine-treatment has been judiciously carried cut, neither 
the amblyopia nor the deviation has probably become extreme or confirmed. 
We wish particularly to emphasize the value of what we have called the 
" atropine-treatment," which may be instituted in babes as soon as squint 
has made itself manifest. In this way a convergent may be turned into an 



DISEASES OF THE EYE. 139 

alternating squint, and both the amblyopia and the extreme loss of muscle- 
balance and development be prevented until an age is reached when specta- 
cles can be worn. But it must be added that for the success of this plan 
of treatment watchfulness on the part of the physician must be supple- 
mented by systematic, persistent, and intelligent co-operation on the part 
of the mother and nurse. 

When the strabismus continues despite the spectacles, long worn, ten- 
otomy of the overacting muscle may be carried out, but never, of course, 
without first having accurate ametropic-correction spectacles ready to be 
worn from the time of the operation. The extent to which the indirect 
fibrous attachments of the muscle are to be cut depends upon the degree of 
the squint. Bat, since the operation is both painless and without great 
danger, it is best to err upon the safe side and cut too little rather than too 
widely. While the tendon is knitting in its new position, all near work 
should be absolutely forbidden except when under the atropiue-treatment 
explained above. Experience shows that the permanent results of the 
operation are not settled for several months. There should, therefore, be no 
haste to repeat or do other operations when at first the results seem unsatis- 
factory. So long as frequent testing shows the muscle-balance to be in a 
state of change for the better, no second operation should be undertaken. 
But if at last it is seen to be necessary, we have to choose between recutting 
the same tendon and a tenotomy of the corresponding muscle of the other 
eye, with an advancement of the tendon of the counterbalancing muscle of 
the squinting eye. It may be necessary to unite advancement to tenotomy 
of the first o^jeration when the deviation is so extreme — thirty degrees or 
more — that even a large single tenotomy will not give motion enough to 
the globe. After the operation atropine should be used in the non-operated 
eye, in order to hold its fellow in function and by use strengthen it. In 
divergent squint tenotomy of the externus is rarely useful without advance- 
ment of the internus. 

Insufficiency, sometimes called latent strabismus, is a term used to 
express those incoordinations of the external ocular muscles in which the 
visual lines of binocular vision still meet upon the object, but in which this 
is efiected by an abnormal strain upon or innervation of certain of the mus- 
cles. It may be called immature strabismus, or strabismus may be called 
adult insufficiency. It is evident that it is a more patent form of ocular 
irritation or " eye-strain" than strabismus, since in it the muscles only 
keep the visual lines joined at the object by abnormal or over action, 
whilst in strabismus strain is renounced with the fact of the squint and 
the giving up of binocular fixation. Insufficiency is almost always 
present in greater or less extent when there has been long-existing 
uncorrected ametropia. As in strabismus, so here also, the interui are 
generally the overacting and the externi the underacting or insufficient 
muscles in hyperopia and hyperopic astigmatism, the reverse being the 
condition in myopic defects. There are also in the majority of such cases 



140 DISEASES OF THE EYE. 

ophthalmoscopic evidences more decided iu one eye of macular injury, with 
pigmentary stippling and abnormalism and subnormal visual acuity. The 
defect is roughly estimated in decided cases by fixing the gaze first upon 
a distant and then upon a near object, and noting the lateral deflection 
of the eye when it is shut out from beholding the object. The more 
accurate measurement is made by placing a six-degree or an eight-degree 
prism, base up or down, before one eye (with ametropia also corrected), 
and a plane colored lens before the other. The two resultant images of a 
flame placed twenty feet away appear to normal eyes in vertical alignment. 
The deviation from verticaluess in eyes with incoordinate muscles is meas- 
ured by horizontally-placed prisms, and gives in degrees the measure of the 
insufficiency. Where the interni are weaker than the externi, or where a 
prism with its base to the nose, axis one hundred and eighty degrees, is 
required to align the two images vertically, it is best to give at once full 
correction of the insufficiency when ordering the refraction correction, the 
amount being; divided between the lenses of the two eves. Where the 
externi are the weaker of the two muscles, and especially if the evidences 
of eye-strain have not been pronounced, the ametropic may be prescribed 
without the prismatic correction. In all low degrees (3—5) of external in- 
sufficiency it is well to try non-correction for a considerable period first. 
When the amount is high, partial correction may be at once given. Tenot- 
omy, either complete or " partial," is rarely necessary in insufficiency, and 
a good, thorough mydriatic refraction will correct both ocular and muscular 
asthenopias. 

EEFKACTION. 

Emmetropia, or refractional perfection of the visual mechanism, exists 
when the image of a distant object (theoretically at an " infinite" distance, 
— practically twenty feet away) is, with paralyzed accommodation, correctly 

and sharply focussed upon the macula. This 
^^^' "• condition is diagrammatically illustrated in Fig. 

6, in which parallel rays of light (that is, those 
nearly or supposedly so) from a distant object 
are united at a point upon the retina. Ametro- 
pia, or refractional abnormality, exists when the 
image is not so focussed. The reason that it is 
necessary to paralyze the accommodative appa- 
ratus to determine these conditions is that the function of the accommo- 
dation consists in bringing to a focus rays from an object nearer than the 
horizon or the so-called " infinite distance." In measurements of the refrac- 
tion of the eye, this function must therefore be left out of the count, in order 
that by our correcting lenses we may put the ametropic eye into a condition 
such that the full amount of the accommodation may be left in reserve for 
" near work." Such a condition may be called artificial emmetropia. The 
varieties of ametropia are hyperopia, myopia, and astigmatism. 




DISEASES OF THE EYE. 141 

Hyperopia, or Hypermetropia, commonly called far-sightedness, is 
that condition of the eye or its media in which, with suspended accommoda- 
tion, the focus of rays of light from a distant object is, or tends to be, behind 
the retina. It may arise from a subnormal refractive power of the ocular 
media (cornea, aqueous, lens, and vitreous), or from an abnormally short 
autero-posterior diameter of the e}'e. The effects in both cases are the same, 
so that clinically the distinction is without interest. From the definition 
above it is readily seen that even for distant objects the accommodative 
apparatus of the eye must exert itself beyond the normal in order to bring 
the focus forward upon the retina. When the object is placed within a 
foot of the eye, the rays from it are of course more divergent and require 
still greater power on the part of the accommodative apparatus to keep the 
focus at the retina. From this excess of work and strain arise most of the 
manifold evils of eye-strain. 

An illustration of the hyperopic condition is annexed (Fig. 7). From this 
it is seen that such an eye is only capable (with suspended accommodation) of 

focalizino; converg-ent ravs. But such rays 

• • Fig 7 

do not exist in nature. Hence the reason ' * 

for the excess of focalizing power required /^ \. 

of the hyperopic eye. Hyperopia is the / ___— — =A-N — 

normal condition of the animal, savage, ""^ 
and infant eye, and from the fact that the \ ^ 

antero-posterior diameter of the eye may \^,__^/ 

increase with growth and age, or that the 

ocular media may gain additional refractive power, it is clear that it is 
possible for a hyperopic eye to become emmetropic, or to progress thence 
into myopia. But these steps can never be retraced : myopia can never 
develop into emmetropia or hyperopia. 

The diagnosis of hyperopia, if the child can read letters or figures, is 
made, and the degree estimated, by means of the test-types and test-lenses, 
the accommodation having been previously paralyzed. Any refraction, of 
whatever nature be the defect, is not to be relied upon as accurate that has 
been estimated with the accommodation functional. The biconvex lens that 
gives normal vision " |^" or greater, is the measure of the absolute refrac- 
tion. But we can l^e sure of this result only when we have proved that no 
astigmatism coexists, and this, if possible, more unexceptionally demands 
accommodation paralysis. Each eye must be tested separately. The work 
as estimated in this way may be "proved" by other methods, — by retinos- 
copy, the ophthalmoscope, the prisoptometer, etc. ; but perfect reliance can- 
not be placed upon any method except the one first briefly described. In 
the case of the illiterate and of young children who have not learned their 
letters, purely objective methods will have to be pursued. Physicians 
vary in their choice in such cases, and the judgment of a skilled special- 
ist is required to make a diagnosis close enough to accuracy to promise 
relief. 



142 



DISEASES OF THE EYE. 



In MYOPIA, or "near-sightedness," the globe is too long or the refractive 
media are relatively too powerful. This condition is illustrated in Fig. 8. 

The natural media focus the rays 

e^^' ' in front of the retina, the eye 
being adapted only for very di- 
-. — , vergent rays, or those from very 
— ~ near objects. Hence to see distant 
objects a concave lens is used, or 
one rendering the rays more diver- 
gent, so that the natural focus is 
put back upon the retina. In both hyperopia and myopia it is the diam- 
eter of the globe along the visual axis that usually decides the condition, 
rather than anomalousness or disease of the ocular media. The eye, as is 
well known, is always under a physiological tension from within outward. 
If, therefore, the sclerotic be weakened beyond the force required to resist 
the outward pressure, there follows a distention at this weak point. Such 
bulging is usually at the posterior pole of the globe (" posterior staphy- 
loma"). The result is myopia. Many theories have been evolved to ac- 
count for the existence and increase of myopia, but almost all investigations 
point to the baneful influence of work at short range that is a result of our 
educational, social, and commercial habits of life. Especially to school- 
pressure, with poor light, improper desks, and other unhygienic circum- 
stances, is credited a large share in the increase of myopia particularly in 
European countries. It should not be forgotten that myopia in the young 
is itself a pathological condition, and should be looked upon as a disease 
whose tendency to increase is to be avoided by all possible safeguards. 

The subjective symptoms of myopia are simple inability to see distant 
objects clearly, and in high degrees of myopia a necessity of bringing the 
book and near work close to the eye. It should be remembered that in 
hyperopia and astigmatic defects we may have precisely the same symptoms, 
but there will in such cases be also one or many of the various reflex and 
irritative symptoms of eye-strain. In myopia uncomplicated by astigma- 
tism and insufficiency there is a noteworthy absence of reflex symptoms. 
This is because, properly speaking, no eye-strain exists. The endeavor of 
the eye is to render the lens flatter or less convex, to relax the accommoda- 
tion beyond its extremest point. Strain may arise from overaction of the 
interni caused by the great proximity of the Avork at near range. 

Objectively the ophthalmoscope reveals choroidal changes and degener- 
ation in the neighborhood of the optic disk (" conus" or posterior staphy- 
loma) and the macula which in malignant or progressive myopia may 
proceed to large atrophic patches, hemorrhages, etc., and even to retinal 
detachment. The diagnosis of myopia is proximately made by the ophthal- 
moscope, but only with certainty by the test-lenses and distant test-letters. 
The accommodation must be paralyzed in order to be sure that astigmatism 
is not present, or, if present, to estimate it correctly. It is commonly said 



DISEASES OF THE EYE. 143 

that a mydriatic is not necessary for the correction of myopia. We would 
not refract child nor adult without it, for we have had many patients who 
had passed through other hands, and who through reliance upon this erro- 
neous rule had missed correction of the complicating astigmatism that was 
the source of the reflex troubles. The weakest biconcave lens which, with 
the astigmatic correction added, gives the best acuity at sixteen inches' 
distance, will be found the most satisfactory for constant use. Full correc- 
tion is another and a fatal common error. In degrees above three diop- 
trics reduction of nearly one-half must be made from full correction, in 
order to give the eye its least straining action for habitual use. The full 
measure of the myopia throws upon the ciliary muscle the same excess 
of work that exists in hyperopia. The amount of the reduction must 
remain a matter of judgment; the size of the defect, amount of accommo- 
dative power, nature of the occupation, etc., are always to be considered. 

Where myopia exists in children and shows a tendency to increase {pro- 
gressive or malignant myopia, — a sad and unfortunate condition), strict in- 
struction should be given as regards the light in near work, which must be 
clear, steady, and strong, and strike the page from behind and one side. 
Large-type books only should be allowed. The book or work must be 
held high and well away from the eye, as nearly upon a level with the eye 
as possible, writing-desks must be sloped and high, the hours of near work 
reduced to a minimum, frequently interrupted, etc. If the myopia, despite 
these precautions, still continue increasing, all near work should be for- 
bidden, and the child made to live as much as possible in the open air, 
being allowed to " run wild." The eyes are certainly more valuable than 
the so-called education. Perhaps after a few years the myopia may become 
stationary, and then studies can be cautiously renewed. But such a sta- 
tionariness does not usually arrive before adult life. 

The word Astigmatism is derived from d, " without/' and ariyixa, " a 
point," — because a cone of light-rays proceeding from a point is, by an 
astigmatic eye, not brought to a point upon the retina, the focus of the 
rays in one meridian being either a little in advance of or a little behind 
the retina. This condition is usually the result of corneal asymmetry, the 
curvature of the diiferent corneal meridians being unequal, and the retinal 
image (with suspended accommodation) being, as a consequence, irregular 
and imperfect. 

Tlie cut on the following page may help to a comprehension of this defect. 
The horizontal lines H, H enter the cornea at its least curved meridian, 
and hence their focus is behind that of the more curved meridian T", T". It 
is thus seen that the figure or image never makes a true point, but is shaped 
as shown by the sectional views in 1, 2, 3, 4, 5, etc. 

It is evident that astigmatism may complicate either hyperopia or 
myopia, and in fact it does do so in the great majority of cases. Astigma- 
tism is said to be regular when the two meridians of greatest and of least 
refraction are at right angles to each other. Irregular astigmatism is rarely 



144 



DISEASES OF THE EYE. 



met with, and is usually the result of wounds or injuries of the cornea. 
When one meridian is emmetropic and the other astigmatic, the variety is 
called simple; when the general refraction is hyperopic or myopic with 



Fig. 9. 







"®" "■ 



coexisting astigmatism, the terms compound hyperopic and compound, my- 
opic are used ; when one meridian is hyperopic and the other myopic, the 
astigmatism is designated as mixed. 

It can be accurately diagnosticated only by suspension of the accommo- 
dative apparatus and the use of the test-lenses, wdth whatever other devices 
the individual choice of the oculist may prefer. The existence of uncor- 
rected astigmatism is a prolific source of mischief, and its complete and 
accurate estimation often demands the greatest skill, patience, and judgment. 
The ciliary muscle by its unequal and partial contraction seeks to neutralize 
the effects of the unsymmetrical cornea upon the traversing cone of light, 
and this unnatural action is often the principal source of the consensus of 
morbid symptoms called eye-strain. Full correction of the astigmatism is 
always to be prescribed for constant use. 

The Consequences of Uxcorrected or Improperly-Coerected 
Ametropia. — Their name is legion. Few subjects in medicine are more 
disastrously and inexplicably misunderstood and ignored than this. Num- 
berless lives have been wrecked in consequence, and there are in every city 
thousands of living examples of the fatal negligence or ignorance of the evil 
influence of eye-strain upon the growing organism and general health. Phy- 
sicians may vainly continue for years to treat their patients with every article 
of the materia medica in the hope of relieving a headache that springs from 
ametropia, a chorea due to eye-strain, or an anaemia or a dyspepsia that arises 
from the malassimilation and anorexia whose proper name would be a 
reflex ocular neurosis. Limitations of space prevent a complete exposition 
of the subject here, and we can only refer to articles previously published.^ 

Concernino; headache, it is at last becoming a matter of common knowl- 
edge among the laity that it may be " due to the eyes." That it is gener- 



^ Especially to Clinical Illustrations of Eeflex Ocular i!Teuroses, by G. M. Gould, M.D., 
in The American Journal of the Medical Sciences, January, 1890. 



DISEASES OF THE EYE. 145 

ally due to them, and that its true origin is frequently unsuspected by the 
general practitioner, is a daily experience of every ophthalmoloo-ist. But it 
is a somewhat novel and apparently absurd thought that the gastric and 
assimilative functions are usually profoundly impaired in the majority of 
cases of severe irritational ametropia. We have found clinically that 
headache usually precedes, and is usually continuous with, the gastric 
trouble. This last commonly consists first in an unaccountable loss or 
fickleness of appetite. As the irritation has created an abnormal amount 
of nervous energy, nature seeks an equipoise by lessening the production 
at the point of origin. The mechanism might be not inaptly likened to 
the governor of a steam-engine, — the greater the speed the more the steam 
is shut off below. An analogous but reverse process physiologically is the 
automatic mechanism whereby deoxygenated blood, by its action upon the 
centres of respiration and cardiac inhibition, quickens the action of the 
heart and lungs. With failing nutrition there is general diminution of 
vitality, a growing languor and malaise, alternating with periods of exces- 
sive hypersesthesia of the nervous system. The irritation continuing, the 
anorexia proceeds to fits of nausea, and even vomiting, ending finally in 
one of the many forms of chronic dyspepsia, or " sick headache." The 
physician has been appealed to, and long courses of dieting, artificial foods, 
bitters, mineral acids, or tonics, have been tried in vain. Doubtless every 
physician vividly remembers a number of such puzzling cases. We have 
had a great many such cases in which, within a week or two after the 
wearing of proper spectacles, the gastralgias, dyspepsias, and loss of appetite 
disappeared, and within a few months the body-weight increased from ten 
to twenty pounds. If the spectacles are accidentally broken, the symptoms 
quickly recur. 

In the young the consequences of eye-strain are exceedingly prone to 
arise or become ingravescent about the time of puberty. There can be 
little doubt that delayed menstruation may be due directly or indirectly to 
eye-strain. Another complaint of parents, and one almost always existing 
in children who are choreic, nervous, and anaemic from ocular irritation, is 
night-terrors, and restlessness. " Has no more nightmare and crying out 
in sleep since getting the spectacles," is a frequent report. We have also 
noted the cessation of nocturnal enuresis, in a few cases under like circum- 
stau(!es. In several cases coming under our observation habitual "car- 
sickness" has disappeared with the wearing of spectacles. It may be worthy 
of question if some causal relation may not exist between ocular defect or 
function and sea-sickness. Tliat chorea may be of ocular origin is now 
admitted by the best diagnosticians. We have had cases of several years' 
standing in young girls who had been persistently but unsuccessfully treated 
with arsenic, the bromides, etc., and in whom all symptoms disappeared 
almost immediately after the wearing of glasses. In others great excita- 
bility, irritability, nervousness, lack of self-control, etc., vanished in the same 
way. These deleterious effects upon the emotions and disposition may — 
Vol. IV.— 10 



146 DISEASES OF THE EYE. 

and, if long continued, must — have their effect upon the entire character 
and after-life. 

Eye-strain may also influence the life in another way, so that occupa- 
tion and pursuits in life are unconsciously governed by it. Study and 
literary labor become so wearisome that the child's mind is influenced 
against them. The parents are grieved that the taste is slowly but irrev- 
ocably turned from intellectual pursuits and the mind directed to physical 
activities for outlets of its energies. The bearing of such facts cannot be 
overestimated when we think of our school system ; our high-pressure 
civilization ; the suddenness of the strain, since the invention of printing, 
thrown at once upon the naturally hyperopic eye ; the interblending of 
ocular functions with every act, physical and psychical ; and the fact that 
the enormous load is thrown upon the young organism just at its most 
plastic and formative period. 

A strange fact relating to this whole class of disorders is that the patient 
may not, and usually does not, feel or exhibit any signs that the eye is the 
source of all these manifold and seemingly distant results. Sometimes 
the eye or its appendages may show the results of its own irritational work. 
In children, styes, blepharitis, and conjunctivitis sometimes exist as the 
evidences of ametropia, but more frequently the reflexes are to the head, to 
the digestive system, or to other special or general organs. 

We have elsewhere attempted an explanation of this peculiar fact in 
one class of cases, especially applicable to girls approaching puberty. The 
essence of the thought is that in the sensitive, emotional, and intellectual 
of both sexes, but particularly in girls and young women, the irritational 
eye-strain reflex that normally or physiologically would return eyeward is 
inhibited, with the result that headaches follow ; or it is derouted to other 
organs that suffer vicariously. The reason of this inhibition, overflow, or 
deroutation is to be looked for in the enormous importance of the function 
of vision to the organism in general, and to an exceptional degree in the 
action of sexual selection, clear and healthy eyes being of the highest im- 
portance in influencing sexual choice through beauty. Hence the corollary 
that the smallest amount of ametropia in girls and women should be cor- 
rected, an amount that in men could be safely ignored. According to the 
fineness or delicacy of nervous organization and the preponderating quality 
of sexual instincts will eye-strain be disastrous to the general health. All 
this applies with less force to non-city-bred children or to those who are 
not pushed by their own ambition, their parents, or the cramming systems 
falsely called educational of many schools, to an excess of book-work and 
accommodative effort as harmful to the eyes as it is, both positively and 
negatively, to the body and brain. However much of the mischief can or 
will be obviated by relief of the eye-strain, — and certainly much can, — a 
liberal surplusage will certainly remain. 



DISEASES OF THE EYE. 147 

WOUNDS AND INJUKIES. 

It should not be forgotten that it is in the treatment of wounds and 
injuries that the general physician will be called upon for prompt and skilful 
service, that upon the results of immediate measures will often depend the 
question of the patient's vision or blindness, and that every case may have 
possible medico-legal complications. In reference to the latter aspect, the 
excellent instruction of Arlt^ is worthy of the study of the careful practi- 
tioner. 

Foreign Bodies. — On the part of grown people there is usually a 
clear history and consciousness of the fact when a foreign body is " in the 
eye," but in children this is not so frequently the case. When there has 
arisen sudden coDgestion of the conjunctival capillaries of one eye, we must 
be on our guard, and at once institute a thorough search for some particle 
of dust, etc., that may be lodged upon or in the conjunctiva, the cornea, or 
in the cul-de-sacs. It is necessary to illuminate the cornea from different 
directions, that a body may be thrown into relief when it is perhaps of the 
same color as the iris-background, or as the tissue itself. If nothing is 
found in the exposed parts of the eye or in the inferior cul-de-sac, the upper 
lid must be everted by grasping the lash, directing the patient to look down, 
and carefully turning the lid upon itself. It is always a cause of wonder 
how small a foreign body can produce such discomfort and })ain, and the 
remark illustrates the necessity of scrutinizing every part, of unfolding all 
wrinkles, and of looking at different angles in order not to miss seeing it. 
Often a two-inch condensing lens will help to illuminate the object. Before 
the examination, or at least before attempting removal of a foreign body 
however superficially located, it is best to use a drop of a two-per-cent. 
cocaine solution. If the particle be loose upon the conjunctiva or cornea, 
it may be brushed off with a moist wisp of absorbent cotton ; but if em- 
bedded, a corneal spud will be necessary for its removal. The instrument 
should be so held that any spasmodic motion of the eye or head will not 
wound the part. When irritated, the eye is rolled upward, and hence the 
instrument should be lightly held. When a cinder or a particle of steel is 
deeply embedded in the cornea, great care and judgment are required. A 
common but a reprehensible practice has been to use astringents in eyes 
from which a foreign body has been removed. It is in no case advisable. 

When a foreign body has penetrated the globe and can be seen in the 
anterioi' chamber, it shoidd be removed by incision in such a manner that 
it can be best reached either by a magnet, if it be steel, or any other instru- 
ment, according to the circumstances and the choice of the painstaking sur- 
geon. The patient should be anaesthetized. Removal of bodies that have 
entered the vitreous chamber requires exceptional skill, and is certainly 

1 Arlt on Injuries of the Eye considered Medico-Legally. Translated by C. S. Turn- 
bull, M.D., Philadelphia, 1878. 



148 DISEASES OF THE EYE. 

not to be undertaken by any but the most experienced hand. If such a 
person can see the patient within a day or two, and before the body has 
become encysted or covered with lymph, it may be removed. But where 
operation is not at once possible or is for any reason inadvisable, it is best 
to have the patient lie rigidly still upon the back and with the head high, 
in the hope that the body will settle in the lower and least-used part of the 
vitreous chamber and there become encysted and stationary. A few cases 
have been reported where foreign bodies have entered the lens and remained 
there without setting up cataract. Of course any attempt to remove such 
would almost always result in rupture of the capsule, with the consequent 
cataract. 

Burns of the Eye, either by dry or by moist heat or by chemically- 
acting substances, are difficult of treatment, and are of such various nature 
that few hints can be given for guidance in this respect. If the injury be 
seen at once and if it be caused by acids, then an alkaline lotion — say, a tea- 
spoonful of bicarbonate of sodium to a cupful of water — is indicated, with 
which the whole eye should be freely irrigated. When the injury has been 
caused by alkalies, — as, e.g., by lime, — then an acid wash — e.g., vinegar 
diluted with one-half water — will be very useful. But in either case no time 
should be lost in waiting for or preparing these things. Water is almost 
always at hand, and with this the eye should be cleansed and thoroughly 
washed. The greatest danger in all cases of burns is that the conjunctival 
surfaces of the opposite lids and globe may have become denuded and in 
healing they may grow together in an incurable symblepharon. The most 
promising way of preventing this is to keep the eye bathed and the sulci 
filled with castor oil, and to break up the adhesions that may begin forming 
by frequently passing a probe or spatula between the surfaces. If the pain 
become intense, cocaine must not be used, but anodynes and cold compresses, 
with paralysis of the accommodation, will be found most efficacious. 

Injuries of the Eyelids require more care and watchfulness than are 
usually given them, owing to the fact that notches and subsequent cicatri- 
zation are very apt to distort and evert the lid, with consequent lachrymal 
troubles, or to invert it, with all the sequelae, pannus, etc., that follow upon 
entropion or inversion or malposition of the cilia. In a general way they 
are to be treated as an injury elseAvhere would be, but with especial refer- 
ence to the peculiar function of the tissues and the dangers we have adverted 
to. Gaping wounds should be most carefully and accurately sutured in 
place, instead of using court-plaster. Owing to the extensive areolar tissue, 
extravasation of blood is common. If the oedema be great, fracture of the 
orbital walls or border should be reckoned among the possibilities. 

Rupture of the Globe is rare, and is usually the result of contu- 
sion with a blunt body. Owing to the fact that the nasal side of the globe 
is more protected than the temporal, the blow is more commonly upon the 
latter side, but by reason of the transmitted force, or " contrecoup," the 
rupture is more frequently in the choroid and upon the nasal side. 



DISEASES OF THE EYE. 149 

Permanent recovery from a rupture through the ciliary region will 
never take place. Tlie subsequent cicatrization will induce cyclitis and such 
irritation that enucleation must follow sooner or later. So that the rule is 
without exception that, where the ciliary body has been certainly broken 
or cut through, immediate enucleation is the better procedure. Even if 
the globe be saved, there is apt to be little vision, and the danger of per- 
sistent cicatricial irritability and sympatlietic inflammation is great. In 
such cases, also, the lens is frequently dislocated and the capsule ruptured,, 
so that cataract is a common complication. If the lens be in the anterior 
chamber, it should be extracted at once. If the lips of a purely sclerotic 
cut or rupture show a tendency to gape, a few delicate stitches may be taken 
through the external edges of the lips of the wound and the conjunctival 
tissues. When the cornea is extensively cut or ruptured and a large part 
of the iris protrudes, this should be drawn out as far as possible and excised. 
This may even have to be repeated one or more times, in order to avoid 
extensive cicatricial inclusion of the iris in the lips of the wound. Accord- 
ing to the location of the wound, the use of eserine or of atropine may be 
advisable to aid in the retraction of the iris. The bandage should be firm, 
but not tight. 

Penetrating Wounds and Sympathetic Inflammation. — Many 
remarkable cases have been reported of the retention of large foreign bodies 
that have penetrated the orbit. In such cases, therefore, one must be on 
his guard not to overlook them, by inquiries as to the exact nature of the 
object causing the traumatism, by careful examination of the wound, etc. 
In perforating wounds of the cornea there will probably be hernia of the 
iris. If this be extensive and cannot be reduced, the protruding portions 
must be excised as deeply within the lips of the wound as possible, and 
the eye atropinized and firmly bandaged. If the hernia recur, the same 
operation must be repeated, since extensive inclusion of the iris in the 
wound is to be avoided at all hazards, a fact that necessitates a subsequent 
iridectomy to release it and to keep the eye from constant pain, iritis, and 
irritation. But if the hernia be of only a small portion of the iris, it is 
best to try the effect of atropine, rest, etc., rather than mutilate the iris, and 
also because if only slight adhesion take place a subsequent iridodialysis or 
iridectomy may remedy the trouble. When the ciliary body has been cut 
through, there is the same danger as that to which we have adverted in the 
preceding paragraph, and enucleation must follow. 

Whether to enucleate at once or not in cases of doubtful implication of 
the ciliary body is often the most perplexing of questions. If not done, and 
fatal sympathetic inflammation ensue, it is of course the saddest of results. 
Tlierefore it is better to err on the side of safety and enucleate, though the 
condition of the injured eye promise some slight chance of recovery. The 
existing complications, the extent of the injury, the condition of the other 
eye, the general health of the patient, etc., must all be considered. At all 
events, and in all cases, careful search must be made for possibly retained 



150 DISEASES OF THE EYE. 

foreign bodies, thorough cleansing and antiseptic treatment instituted, 
perfect quiet enjoined, etc. 

Sympathetic trouble may not only follow traumatism, but may also result 
from any destructive disease of the eye, especially of the ciliary body. In 
such cases, that primarily injured is called the excitor, the other the sym- 
pathizer. Sometimes the excitor is a shrunken globe that in consequence 
of extensive choroidal or ciliary disease has become affected with phthisis 
buibi or progressive atrophy and shrinking. It is customary to divide 
sympathetic trouble into two groups, — sympathetic irritation and sympa- 
thetic inflammation. The method by which the sound eye is affected by 
the excitor is a matter not yet wholly made manifest. Clinically, the period 
of irritation — consisting (in the sympathizer) in limitation of the accom- 
modation, sharp pains, photophobia, lachrymation, congestion, etc. — is of 
extreme importance, as heralding the probable approach of a true inflam- 
mation, an irido-cyclitis. In either stage the earliest possible enucleation 
of tlie excitor is imperative. 

SURGICAL OPERATIONS UPON THE EYE. 

In all operations upon the eyes of children, it is better to ansesthetize 
the patient. The operation can frequently be done during the primary 
effect of ether or chloroform, when properly given. The stomach should 
be empty, food having been forbidden for several hours prior to the opera- 
tion. Subsequent to the operation, we should see that gastric pain does not 
arise, causing the child to cry, and thus endangering the success of the 
operation. Paregoric is probably the best anodyne in such cases. A small 
mustard plaster over the epigastrium, and other measures, may be ordered, 
according to the circumstances or the preferences of the physician. It is 
generally useless to attempt bandaging the eyes in the case of an infant; on 
account of the absence of hair, the smoothness of the scalp, etc. Where a 
bandage is necessary, it may be retained in place when placed over a tight- 
fitting cap or hood. A dark room is usually preferable to bandages. 

Operations to Relieve Obstructions of the Lachrymal Ex- 
cretory Apparatus. — Epiphora may arise from an excessive secretion 
rather than from an impeded outflow, and doubtless operations upon the 
canaliculi and duct have sometimes been carried out where more careful 
search would have shown some reflex or other source of local irritation to 
account for the excess of tears in the eye. Sometimes, also, the canaliculus 
and duct are normally patent, but the puncta are either slightly everted, or 
closed by a foreign body, or stenotic from inflammation or cicatricial contrac- 
tion. In these cases it is unnecessary to slit the canaliculus or to probe the 
duct, and where there is not positive evidence of nasal disease or dacryocys- 
titis, it is better to begin by opening or extending the opening of the puncta. 
When there is not perfect apposition of the puncta to the globe, a simple pro- 
ceeding consists in inserting the sharp point of the scissors into the opening 
and dividing the conjunctival surface vertically downward for one or two 



DISEASES OF THE EYE. 151 

millimetres. AYhere this is insufficient, or where it is necessary, on account 
of purulent disease of the sac, to divide the canal lengthwise, a peculiar 
blade is used — Weber's canaliculus knife — with a tiny bulbous point which 
guides the advancing knife along the tube. The physician, standing over 
the anaesthetized patient, uses one hand to withdraw the lid from the globe 
and make it tense, steady the head, etc. The bulb having entered the 
puncta, the knife is held horizontally and is advanced along the canal until 
the bulbous point reaches the lachrymal sac ; then, while the lid is held by 
the thumb of the other hand firmly to the temporal side and kept tense, the 
knife is raised to a vertical position and the canaliculus is divided up to 
the mouth of the sac. Constriction of the nasal duct may be incised by 
now rotating the cutting edge of the blade anteriorly and pushing the knife 
downward and slightly forward into the cavity of the duct. Sometimes the 
duct shows a persistent tendency to constriction and closure, though this is 
seldom seen in children. If so, a probe made for the purpose may be used 
till the duct remains patent. Care must be used that the probe do not 
form a false passage, and also that it be inserted properly. Acute abscess 
of the lachrymal sac should be immediately and freely opened, and after 
this watchfulness exercised that a lachrymal fistula do not form. 

Meibomian Cyst. — Upon everting the lid we sometimes find the cause 
of conjunctival congestion in a localized purplish discoloration and swelling 
of the subconjunctival tissues. The duct of a Meibomian gland having 
become occluded, its retained secretion causes distention and inflammation 
of the part. It should be freely incised upon the conjunctival surface, and 
the contents removed by scoop and scraped with a sharp spoon. 

Blepharoplasty. — Plastic operations upon the lids are for the pur- 
pose of correcting entropion, ectropion, cicatrices, or injuries, and for the 
rare congenital ptosis from lack of development of the muscular fibres. 
When in entropion only a few hairs are incurved, they are best destroyed 
by electrolysis, or given a difPerent direction by illaqueation, which consists 
in drawing each lash through a needle-hole by a lasso or loop of ligature. 
The tissue containing the hair-bulbs of the lashes may also be excised from 
the inner margin of the lid after dissecting away the conjunctiva. 

If a large extent of the lid is turned in, more radical measures are 
required. The most common mode of correcting this in the lower lid is by 
removing a strip of skin parallel with the lid-edge, the width and depth of 
the portion of excised tissue being proportional to the effect desired. If of 
the upper lid, the choice lies between several operations. 

The Jaesche-Arlt operation consists in splitting the lid along the inter- 
marginal edge three or four millimetres deep. The anterior portion con- 
taining the cilia is made free except at the ends by an incision through the 
skin of the lid about three millimetres from the edge of the lid and par- 
allel with the same. Above this a fold of skin is removed entirely, corre- 
sponding in size with the effect desired, and the ribbon of tissue containing 
the cilia is brought up and fastened in the space of the excised tissue by 



152 



DISEASES OF THE EYE. 



sutures, thus bringing the edge of the lid with its cilia into a normal posi- 
tion. Von Graefe's operation is similar, except that vertical incisions one- 
third of an inch long are also made from the two extremities of the ribbon 
of cilia-tissue, and the ends of the same near the canthi are better elevated 
by sutures into the outer lips of the vertical incisions. Hotz excises a layer 
of muscular fibres over the tarsus three or four millimetres in breadth at 
the upper border of the tarsus of the upper lid or the lower border of the 
tarsus of the lower lid, and sutures are passed through the upper edge of 
the tarsus. In Dianoux's operation two parallel bands, one containing the 
cilia, the one above it simply the skin, each about three millimetres broad, 
are made by splitting the lid and by an incision })arallel to the lid-edge 
extending to the cartilage. The upper is drawn under and below the lower, 
and its lower edge sutured to the conjunctival edge of the lid ; the ribbon 
of cilia-tissue is thus raised from the border of the lid, and its upper 
margin is sutured to the lower of the superior incision of the lid. Streat- 
feild and Snellen remove a V-shaped wedge of skin, muscle, and tarsus 
parallel with the lid-edge ; and Von Burow's operation consists in a con- 
junctival incision of the cartilage three millimetres from the border of the 
lid, causing gaping of the wound and moderate eversion of the free edge. 

Wharton Jones's operation for ectropion is illustrated in the annexed 
cuts (Figs. 10, 11). A V-shaped incision is made with the limbs extending 



Fig. 10. 



Fig. 11. 









Wharton Jones's operation for ectropion. 



toward the canthi. The enclosed triangular flap of skin is then dissected up 
and reduced by excision to the desired extent, and the lower part of the in- 
cision brought together by sutures, so that the final appearance of the wound 
is that of the letter Y. The contraction thus produced by the cicatrix brings 
the lid into apposition with the globe. Argyll-Robertson's operation con- 
sists in inserting into the lower cul-de-sac a piece of sheet-lead about the 
size of the lid and conforming to the parts in shape, against which the lid 
is brought into apposition and the normal position by tension upon ligatures 
passed from without through the free edge of the lid, thence through the 
bottom of the cul-de-sac out upon the cheek below. Bits of rubber tubing 



DISEASES OF THE EYE. 



153 



are used under the external loops of the ligature, to prevent their cuttiug 
through the integument, before traction is made. If the lid be thickened 
by an overgrowth of subconjunctival tissue, a V-shaped mass may be ex- 
cised the length of the everted lid, prior to the ligation. 

It may be said that operations of this kind are rare in children, though 
sometimes necessary or possible in those approaching puberty. The carti- 
lage in children is not fully developed, and this fact must be considered 
when operations are done on the lids. 

Traumatic or cicatricial ectropion can only be cured by transplantation 
of a flap with pedicle from the adjacent forehead, temple, or cheek, or from 
the arm, or by transplantation without pedicle from the arm. The un- 
sightliness of the facial wound thus produced gradually grows less in time, 
and the flap from the face usually gives the best result. It must be larger 
than the freshened or denuded space it is to fill. An ingenious method 
of repairing a loss of tissue at the canthus is shown in the annexed cuts 
(Figs. 12, 13). The space a being denuded and freshened, the flap b is 



Fig. 12. 



Fig. 13. 




/ 'h 




Hasner d'Artha's blepharoplastic operation. 



dissected up, twisted upon the pedicle c, and the points d and e are sutured 
to the lower and upper lid so as to form the normally-shaped angle between. 

Peritomy, the object of which is to relieve pannus by a dam of cica- 
tricial tissue about the cornea, is performed by dissecting off a ribbon of 
conjunctiva one or two millimetres wide close to and encircling the cornea. 
It is rarely required in children. 

Dense corneal staphyloma, or bulging of the weakened cornea from 
the intraocular pressure, may be removed in several ways, one of which is 
shown in the illustration following (Fig. 14). The main body of the staphy- 
loma having been removed by two incisions through the dotted lines, the 
sutures are at once tightened and a movable stump thus obtained. Another 
method is to run a strong continuous ligature through the healthy loosened 
and undermined conjunctival tissue and sclera surrounding the staphyloma, 
so that, after excision of the latter, traction upon the ligature acts like a 
" puckering-string" and at once closes the conjunctiva over the space of 
the excised tissue. Mules, of England, advises clearing out the entire 
contents of the globe and filling the cavity with a glass ball. 



154 



DISEASES OF THE EYE. 



In cases of dense corneal leucoma the unsightliness may be greatly 
improved by tattooing the cornea, by which a close approach to the 
appearance of a pupil may be made. 



Fig. 14. 




Operation for corneal staphyloma. 



The incision for iridectomy, or to make an artificial i^upil, is shown in 
Fig. 15. The knife used is a triangular keratome, and is entered at the 



Fig. 15. 




Iridectomy. 



corneal limbus or border from above and to a depth requisite for the 
proposed operation. The iris is then seized at the pupillary border by the 



DISEASES OF THE EYE. 



155 



iris-forceps, withdrawn, and a piece, of the size and shape desired, excised by 
one stroke of the scissors. Atropine, to pull the iris ends out of the wound, 
is periodically instilled, and the eye kept bandaged for two or three days. 
This operation is useful in anterior or posterior synechia, to make an arti- 
ficial pupil in case of partial opacity of the cornea, and also as a thera- 
peutic measure in glaucomatous tension caused by adherent leucomata. 

Discissiox, OR Xeedlixg, is an operation frequently required in con- 
genital cataract of the young. The adjoining cut (Fig. 16) gives a good 

Fig. 16. 




Discission, or needling. 



idea of the proceeding. The point of the stop discission-needle is passed 
into the anterior chamber from the side of the cornea and past the dilated 
pupil until it pierces the anterior capsule and the substance of the lens ; 
by movement of the point the capsule must be freely ruptured and the lens 
broken up to the desired extent so that the aqueous shall gain admission to 



Fig. 17. 




Discission, or needling, with two needles. 



it, causing it to swell and become opaque and finally to break down and be 
absorbed, leaving an unimpeded path for the light. In recurrent or cap- 



156 * DISEASES OF THE EYE. 

siilar cataract after an extraction of the lens the same operation is made use 
of to break through and depress Out of the way the central portion of the 
opaque capsule. Two needles are commonly used for this purpose, as 
shown in Fig. 17, whereby an opening is more certainly and accurately 
made by rupture and displacement outward of the capsule by the two 
needles meeting first at the centre of the pupillary space. No reaction 
usually follows the operation. 

Tenotomy in Case of Strabismus. — Graefe's subconjunctival opera- 
tion is the proper one in these cases. The opening is made at a point tan- 
gent to the lower edge of the cornea. The conjunctiva and Tenon's capsule 
are vertically cut across over the lower edge of insertion of the muscle-ten- 
don, and the opening widened sufficiently for operative purposes. The stra- 
bismus-hook is then inserted beneath the tendon, which is drawn forward, 
and, by inserting the blades of the scissors (blunt points and curved on the 
flat) between the hook and the globe, the tendon is divided close to the 
globe. If the most extreme effect possible is desired, the lateral and pos- 
terior attachments of the capsule of Tenon may be divided. A suture may 
be used to close the conjunctival opening and drawn more or less tight to 
reduce the effect of the operation. Put atropine into the fellow-eye, or use 
correcting spectacles at once. 

Advancement. — When the effect of a tenotomy is insufficient to give 
the desired change in the visual axis, it must be repeated when the opposing 
muscle is advanced. To do this, a ligature passed about the tendon at its 
insertion firmly secures the muscle by the loose ends of the ligature. The 
tendon is then divided close to the sclerotic and its lateral attachments are 
freely divided. Another ligature is now passed through the muscle behind 
the one grasping the cut end, which last is excised with as much of the 
tendon itself as is desirable to give the effect of increased power over the 
globe. The free ends of the ligature passed through the muscle are now 
passed through the pericorneal conjunctival and subconjunctival tissue 
above and below, and traction and knotting secure the divided tendon in 
its new position till union has taken place. It is generally considered best 
to make about one or two millimetres of over-effect at first. If the strength 
of the sutures is doubtful, a stay or anchor suture may be made from the 
skin of the inner canthus. 

Prince's " pulley" operation is perhaps preferable. A ligature is passed 
vertically in and out several times through the conjunctiva one millimetre 
from the cornea in the line of the muscle. An opening is then made over the 
tendon-insertion, and, without dividing it, the muscle is loosened from its 
attachments behind its insertion, so that a second ligature may be passed 
through the conjunctiva and muscle at this place. The tendon is then cut 
at a point removed from the insertion proportionally to the effect desired. 
The first or anchor suture near the cornea is now made into a loop by tying, 
one end of the suture through the muscle having first been passed through 
or under the loop to be made. It is obvious that traction upon the ends of 




Normal Eye-Ground of an Individual with Light-Brown Hair. (Jaeger, Beitriige zur Pathologie 

des Anges, Taf. I.) 



DISEASES OF THE EYE. 157 

the ligature through the muscle acts now like a pulley to draw the cut end 
of the muscle forward. The amount of advance may at the time or sub- 
sequently be regulated at pleasure. 

If vomiting is threatened during an operation for tenotomy or advance- 
ment, the speculum should be quickly removed and firm compression made 
by the hand protected by cotton or a bandage. This is done in order to 
avoid subconjunctival hemorrhage and the rare but possible and disastrous 
result of a hemorrhage into Tenon's space, whereby mobility of the eye 
is destroyed and other complications may ensue from the presence of an 
extensive clot. 

Enucleation of the Eyeball. — The patient is anaesthetized, as in 
every case of manipulation of the eyes of children, the eyelids are held 
apart by a speculum, and the globe is held by the fixation-forceps. The 
conjunctiva is separated from the corneal attachment as close to the cornea 
as possible, with a pair of curved blunt scissors. Tenon's capsule is then 
opened over the insertion of the external rectus, which is now caught with 
the strabismus-hook and divided close to the globe. Each of the muscles 
is in turn then severed in the same way until the globe is held only by the 
optic nerve. Passing the scissors on the nasal side between the capsule of 
Tenon and the globe, and pressing the globe upward, the nerve is divided 
close to the globe in ordinary cases, but as far back as possible in case the 
enucleation is made during or following malignant disease. Antiseptic 
sponges or a pledget of sublimated cotton may be used to arrest the slight 
hemorrhage. After thoroughly cleansing the socket, the lashes should be 
softened by vaseline, to keep them from becoming matted together. A firm 
bandage should be applied for twelve hours, and the socket cleansed and 
dressed for several days until healing is well advanced. 

Artificial Eyes can be worn in two or three weeks after enucleation. 
In all cases the eye should be too small rather than too tight or prominent. 
It should be removed every night, kept in an antiseptic liquid overnight, 
and anointed with vaseline prior to insertion. When it becomes rough 
from long wear, it should be repolished or another substituted for it. The 
socket should be cleansed with an antiseptic lotion once a day. It may be 
added that the art of choosing and fitting artificial eyes requires excep- 
tional skill, judgment, and experience. The stock to choose from must 
be very large, and the conformation of the socket studied in order to give 
comfort to the patient and an approximation to the normal mobility and 
appearance, which is sure to follow a properly-removed globe. 



OPHTHALMOSCOPY: LOCAL DISEASES AND 

FUNCTIONAL DISORDERS OF THE CHOROID, 

OPTIC NERVE, AND RETINA. 



By CHAELES A. OLIYEE, 3I.D. 



HuGHLrjfGS Jacksox once said, " It is, I submit, imperative in all cases 
of severe cerebral disease, at all events in cases of an acute kind, to examine 
the eye with the ophthalmoscope, whether the patient complains of defec- 
tive sight or not :" this assertion he has since made much stronger by 
adding the words " even if he affirms that he can see well, and if he reads 
small tvpe readily." To this we may add that proper and careful ophthal- 
moscopic examination should be made in all cases where organic disease of 
any related kind is suspected. AVith the present inadequacy of knowledge 
of the exact relationship between certain visible intraocular changes, and 
the many varieties of supposed causative systemic disturbance, it is, of 
course, impossible to give any typical description of the changes that may 
occur in the two most important ocular registers (the retina and the optic 
nerve), although in any definite disorder this difficulty will undoubtedly 
be greatly removed by strict, frequent, and painstaking observance of the 
method. 

Here, idiosyncrasies, like those in any other part of the organism, are 
so numerous, and congenital abnormalities, though slight and often un- 
noticed by the incompetent observer, are so frequent, that mistakes must for 
a long time in the future be expected, until thorough systematic exercise 
with instruments of greater power" has rendered the method a certainty. 

AVith the present plan of study by means of the ophthalmoscope, a 
background comprising nerve-tissue, connective material, and a portion of 
a peripheral vascular circle is stretched before us. Its various parts are 
all arranged in a definite way. The intraocular bulbar ending of the second 
nerve — the so-called optic disk — is most frequently recognized as a small 
oval expanse of lighter color than the rest of the ground situated to the 
inner side of the ophthalmoscopic field. From some part of its surface 
can be seen an entering vessel dividing into numerous stems, which by the 
color and reflex of its contained blood, its comparatively smaller size, and 
158 



OPHTHALMOSCOPY : LOCAL DISEASES. ^ 159 

• its lesser tortuosity, can be readily differentiated as an artery from the 
branches and main trunk of the outgoing veins : one is the central retinal 
artery, and the other is its corresponding vein. 

Systematic and careful study will soon render an observer able to note 
the many differences in the appearance of these structures, and to draw 
proper conclusions as to whether there are departures from what is under- 
stood to be normal. First studying any change indicative of abnormality 
and of local disease alone, we will finally consider those alterations which 
ofttimes indicate the existence of systemic disease. 

The instrument should be of the best pattern, and the observer should 
be sufficiently taught to note understandingly what he sees. Careful record 
should be made of the details of the fundus, no matter whether they are 
pathologically interesting or not. Every detail should be written, so that if 
there be any future change the comparison will become at once apparent.^ 

The classification which follows has been made not only because there 
is at least some anatomical correlation between the special form of local 
disease and the gross systemic lesion, but also for convenience of handling 
the material whilst in search of related changes. Of course, in the present 
chaotic state of etiology, it would be impossible to assert dogmatically the 
position of any symptomatic form of disease of the choroid, optic nerve, 
and retina, as having origin in any certain structure ; but wherever the 
position is fairly definite, or the symptomatology points more especially to 
the situation of the general disease, the changed condition of these portions 
of the ocular apparatus will be noted in the text. 



T. LOCAL DISEASES. 

MALFOEMATIONS AND ABNOEMALITIES. 

Malformation in the shape of the disk, irregularities of size independent 
of refractive error, changes in the apparent surface not the result of patho- 
logical condition, and alterations in the character of the physiological 
excavation, have all been mentioned by various authors. 

Both Fuchs ^ and Loring ^ have seen the disk covered by a thin opaque 
membrane, which concealed the entrance and exit of the retinal vessels : 
this anomalous condition of the liead of the nerve does not seem to inter- 
fere with vision in any way, on account of its situation in the blind spot 

^ In all ophthalmoscopic examinations, the writer has endeavored to make it an inflex- 
ible rule to obtain in association as many of the ophthalmic conditions as possible ; and in 
numerous instances he has been rewarded by the discovery of an ocular symptom that has 
proved of immense collateral advantage. 

2 Archiv fiir Ophthalmologie, xxviii. 1, 139, 

* Text-Book of Ophthalmoscopy, p. 98. 



160 OPHTHALMOSCOPY : LOCAL DISEASES. 

of Mariotte in the visual field. The writer has recollection of a very in- 
teresting example in the right eye of a young girl treated in the out-door 
patient department of Dr. William F. Norris's service at Wills Eye Hos- 
pital. Vision and accommodation were both normal after correction of an 
existent ametropia, and the visual fields were apparently not reduced or 
disturbed in any way. 

One of the most frequent variations in the choroidal structure is that 
of the pigment. Instead of being ideally perfect in distribution, as is so 
frequently seen in diagrammatic sections of the human eye, it often forms 
areas of aggregation, etc., as, for instance, around the edges of the optic 
disk. Here, as we so frequently note, the masses assume definite forms, 
such as rings, loops, and crescents ; these, as is well known, are by far the 
most common upon the lateral borders of the nerve-head, especially to the 
outer side. If these groupings are not more than ordinarily pronounced, 
the case cannot be considered atypical. Again, in many instances, where 
there are no special appearances of choroidal inflammation, the heavy black 
interspaces between the choroidal vessels are plainly visible in the periph- 
eral portions of the fundus. Moreover, isolated aggregations of pigment 
may from time to time appear in cases that do not present any assignable 
cause or reason for such occurrences, except the possibility of low grades 
of choroiditis during the child's iutra-uterine existence. Loring^ cites a 
remarkable instance, and Jaeger^ gives an almost similar case, except that 
in his case the massings of pigment were situated in the superior temporal 
portions of the fundus. 

Just as in the lower forms of animal life, where we have individual in- 
stances of great deficiency of general pigmentation, so here in the uveal tract, 
the choroid is made to suffer. Although grading from the most pronounced 
types of African negro to the lightest Caucasian the amount of pigment is 
constantly decreased, yet in both of these extreme types of man we not 
unfrequently have exceptional examples of great decrease of the amount of 
pigment ; these cases being classed under the generalizing term albinism. 
Here the fundus is almost brilliant in appearance, the underlying vessels of 
the choroid being plainly visible. Jaeger {loc. cit.) gives us a beautiful 
chromo-lithograph of this condition. Most frequently the region of the 
macula suffers the least, there generally being a fair amount of pigment 
situated in this portion of the fundus. 

Congenital deposits of pigment upon the disk-surface, from the very 
minute quantities so ordinarily seen, up to the dense massings depicted as 
such by Jaeger,^ should not be confounded with pathological change. Sim- 
ilar pigmentations as seen by Liebreich ^ are sometimes met with in varying 
amounts, from the narrow concentric and line-like aggregations bordering 



1 Text-Book of Ophthalmoscopy, Part I., 1886, Plate II. Fig. 5. 

2 Beitrage zur Pathologie des Auges, 1856. ^ Ibid. 
* Atlas of Ophthalmoscopy, Plate. XII. Fig. 3. 



OPHTHALMOSCOPY : LOCAL DISEASES. 161 

the edge of the nerve, down to almost entire deficiency, as in albinism, 
where the underlying choroidal structures are jDlainly visible. 

Ahnoi^mcd tint of the dish-substance has been mentioned, as, for instance, 
in Case VI. of Jaeger's collection, which if studied by artificial light (the 
condition under which it was sketched) gives a distinct bluish cast. 

Jaeger^ and Mauthner^ have described what they terra an abnormal 
transparency of the nerve-fibres, giving the disk an appearance of greater 
depth than usual : this, which might be supposed to be due to transparency 
of the transverse bands and vessels of the lamina, is explained by Loring ^ 
on the supposition that the lamina is really situated more posteriorly. Loring 
says that he has never seen this condition, but has recognized what appeared 
to be an abnormal transparency of the nerve, " in which minute vessels 
appeared to be embedded as if in some gelatinous substance." This he 
attributed " to a lack, or almost entire want, of connective-tissue elements, 
and to a paucity of the smaller vessels." If carefully searched for, this 
condition will be found to be more frequent in children than may be sup- 
posed. In not a few instances, small irregular areas can be distinctly dis- 
cerned, especially to the temporal side of the nerve-head, in which the nerve- 
substance appears normally more transparent than in the adjacent parts ; 
these in most cases being bilateral, and seemingly unassociated with any 
apparent pathological change. 

Cases of retained nerve-sheaths are sometimes seen, where instead of the 
opacities of the medullary sheaths terminating at the cribriform plate of the 
oi3tic nerve, they either gradually lessen and cease at different distances out 
in the retina, giving somewhat the same appearance that is normally seen 
in the fundus of the eye of the rabbit, or the fibres seem to become trans- 
parent and opaque in turn, leaving islets of whitish striated massiugs, as 
described by Beckmann * and Von Recklinghausen,^ in which special cases 
the condition was substantiated by post-mortem examination made by Vir- 
chow. Schmidt^ reports a similar case confirmed by autopsy. Jaeger'' 
depicts an instance in an otherwise healthy eye. Liebreich ^ gives two in- 
stances, the first of which is remarkable not only for its immense area and 
thickness, but also as exhibiting a small isolated spot far removed from the 
general mass. Juler ^ gives two unusually well marked examples. In both 
of his cases the medullation seemingly begins at the edge of the disk, and 
is curiously divided into four comet-like processes extending along the lines 
of the larger retinal vessels some distance into the periphery of the fundus. 



1 Einstellungen des dioptrischen Appai'ates, S. 31. 
^ Lehrbuch der Ophthalmoscopie, S. 258. 
^ Text-Book of Ophthalmoscopy, p. 100. 

* Archiv f. Path. Anat., xiii. 97. ^ Ibid., xiii. 357. 

® Klinische Monatsbliitter fiir Augenheiikunde, 1874, S. 186. 
' Hand-Atlas, Taf. VI. Fig. 36. 

8 Atlas of Ophthalmoscopy, 1870, Plate XII. Figs. 1 and 2. 
^ A Hand-Book of Ophthalmic Science and Practice, 1884 (Amer. edit.), p. 201. 
Vol. IV.— 11 



162 OPHTHALMOSCOPY: LOCAL DISEASES. 

Noyes ^ also exhibits a drawing of the same condition. The accompanying 
phototype from a sketch which was kindly made for the writer by Dr. B. 
Alexander Randall shows one of the most marked examples seen in the 
writer's collection. The boy, aged nine years, applied for the correction of 
an error of refraction (H + Ah), never having had any subjective symptoms 
of the condition. 

The diagnosis, which is quite easy after having once encountered a case, 
is based upon the peculiar glistening character of the whitish-yellow striation 
(slightly greenish at times) and the fringe-like border of the distal extrem- 
ities. As a rule, the opacity seems to prefer association with the course of 
the retinal vessels, which it more or less conceals. In the annular variety 
(as in the sketch) the centre of the nerve, as a rule, is visible, and presents, 
most probably by surrounding contrast, a very peculiar green tint. The 
calibre of retinal vessels seems in no way impaired, and the color of the 
contained blood appears normal. The uninvolved portions of the fundus do 
not show any indications of pathological process, and, curiously, the macular 
region is seldom involved. Harely and only in the extreme cases is defective 
vision complained of; this, when present, in the opinion of Mauthner,^ 
appearing to be partially the result of high hypermetropia with so-called 
"amblyopia ex anopsia." Be this as it may, it is positive that if careful 
examination of the vessel-fields be made in all such cases, corresponding 
defects will be found, whilst the unaffected areas of the ground seem to 
project normal eolor-differeutiation. In most of the cases seen by the 
writer the anomaly has been unilateral, and in none of the few instances 
searched for has he been able to find a similar condition in the parents. Of 
course, treatment is out of the question. 

As it is well known that the greatest amount of optio nerve masdngs 
is found at the inner upper and lower portions of the disk, thus practically 
giving greater elevation to the nerve-substance in these situations, it may be 
interesting to note an instance in a boy described by Mauthner,^ in which 
the fibres appeared to be caught into two bundles, one above and the other 
below, holding the entire retinal circulation within their grasp ; this appear- 
ing in an eye where astigmatism of sufficient amount to produce a similar 
picture did not exist. 

Coloboma of the choroid, which is generally situated inferiorly, is usually 
associated with colobomata of the iris and lens. The defect appears as a 
large ectasia or series of depressions, separated from the non-colobomatous 
portion of the eye-ground by an irregular black line of pigmentation. If 
carefully looked for, the retina appears as a thin filmy haze stretched over 
the entire surface. If the coloboma be typical, it gives the effect of a large, 
glittering, whitish, and irregularly concave piece of enamel, containing in 
places a fine radiating net-work ; the whole being covered by a delicate 

1 A Text-Book on Diseases of the Eye, 1890, Plate III. Fig. 2. 
'^ Lehrbuch der Ophthalmoscopie, 1868, S. 2GG. 
^ Virchow's Archiv, x. 267. 



PHOTO. II. 




CoLOBOMA OF THE CHOROID. (Jaeger, Beitrage zur Pathologie des Auges, Plate XLVI.) 



OPHTHALMOSCOPY : LOCAL DISEASES. 163 

grayish veil carrying a series of interlacing, larger, bright- and dark-red 
lines. Most frequently the ectatic portion is divided into a series of 
irregular depressions into which the retinal vessels may dip. At times the 
nerve-head itself, especially if it be partially or wholly included in the colo- 
bomatous area, appears of a peculiar greenish-gray tint (gas-light), with 
very little capillarity in its substance. In such cases the retinal circulation 
is impaired, and the vessels themselves are small and irregular. Again, 
many small scleral shoots from the posterior ciliaries may appear at points, 
showing themselves, as Loring says,^ as a fine delicate net-work, of which 
isolated branches here and there can be traced directly into the sclera or 
followed over the white surface of the coloboma into the normal district of 
the choroid. Should the choroid show signs of disturbance, or should the 
depressed areas contain much pigment-massing, it is most probable that the 
case is not one of true defect, but is the result of inflammation during foetal 
life. Vision is always affected in a position corresponding with the area 
of deficiency. Benson ^ adds a case of uniocular coloboma of the choroid 
with colobomata of the iris and lens in a twelve-year-old boy. The fundus 
in the colobomatous area was four diopters lower than the sound portion, 
which itself was highly myopic, whilst the normal background of the 
fellow-eye could be seen with a convex lens. The accompanying repro- 
duction of the ordinary condition seen is from Jaeger (Plate XLVI.). 

Colobomata of the sheaths of the optic nerve, described by Liebreich,^ 
Makrokoki,* Nieden,^ Randall,^ and others ; colobomata situated in the 
macular region, as seen by Burnett and Reich,^ and the questionable one of 
Loring ; ^ the curious coloboma to the nasal side of the eye-ground, associ- 
ated with acquired changes, seen by De Schweinitz and Randall,^ and one 
very interesting, still unpublished case by the writer, where there is a small 
ectasia utterly devoid of any inflammatory products, situated just up and in 
from the left disk of a young girl, are all extremely rare. The pictures 
they present are so typical of malformation that when carefully studied 
it is impossible to confound them with apparently similar conditions de- 
pendent upon traumatism or disease. Two additional cases involving the 
macular region are described by Silex.^" Here, however, as the author says, 
the changes are most probably dependent upon intra-uterine choroiditis, 
and are not (jaused by faulty development. 

Idiosyncrasies in vascular distribution to the optic nerve and retina are so 

1 A Text-Book of Ophthalmoscopy, Part I., 1886, p. 93. 

2 Transactions of the Ophthalmological Society of the United Kingdom, 1884, p. 857. 

3 Atlas d'Ophtalmoscopie, Plate VII. Fig. 4. 
* Archiv fiir Augenheilkunde, xxi. 29. 

= Archives of Ophthalmology, viii. 50L 

6 Transactions of the American Ophthalmological Society, iv. 558. 

'' Archives of Ophthalmology, xi. 461. 

^ Text-Book of Ophthalmoscopy, p. 95. 

® Archiv fiir Augenheilkunde, xix., Taf. IV. 

icibid., March, ^1888. 



164 OPHTHALMOSCOPY: LOCAL DISEASES. 

pronounced and frequent that it is sometimes questionable whether to legiti- 
mately class them as abnormal or not. Curious twistiugs, redoublings, and 
intertwinings of the retinal vessels, especially near or on the disk, are of 
frequent notice. An excellent example of this occurring in the inferior 
artery of the retina is described by Little ^ under the title of " A Case of 
Persistent Hyaloid Artery." Czermak ^ reports an almost similar instance. 
Under the title of "A Case of Tortuosity of Retinal Vessels, in Connection 
with Hypermetropia," Mackenzie ^ gives a sketch of curiously twisted and 
redoubled retinal vessels which he saw in the left eye of a twenty-year- 
old girl. 

Post-natal persistence of the hyaloid artery of foetal life, usually present, 
according to Miiller,* in oxen and some other animals, such as swine, the 
moose, and the sheep, has been seen and described in man by Hannover,* 
De Wecker,^ Little,^ Kipp,'' and others. It appears generally as a wavy 
slender cord running forward from the excavation of the disk out into the 
vitreous, sometimes extending sufficiently far, as in one case observed by 
the writer, to spread out over the posterior pole of the lens into a series 
of minute capsular branches. It is very seldom patulous, as in a case of 
Zehender's.^ Seeley^ gives the sketch of one in which the detachment 
occurred at the nerve. Manz'" has described an almost similar condition 
post mortem. Despagnet^^ cites a case of monocular persistence of the 
canal of Cloquet without other abnormality of the eyes : this is very in- 
structive in view of the fact that Everbusch thinks that many so-termed 
instances of persistent hyaloid artery are in reality nothing but the ordi- 
nary canal of Cloquet as found in man, rendered visible to the ophthalmo- 
scope by intraocular irritation and inflammation. Liebreich (vide article 
by Little, loc. cit.) instances a supposed case of persistent hyaloid vein, but, 
as Little justly asserts, there is no anatomical proof of the existence of 
such a venous trunk. The condition is usually unilateral, although Ivipp's 
case (loG. cit.) was binocular. Care should be taken to avoid confusion 
with new blood-vessel formations, which from time to time have been noted 
by most competent observers, — these later conditions being nothing but 
part and parcel of coexistent inflammatory results. Of cburse, if the em- 
bryonic remains are large and extensive, and the case one of long standing, 
consecutive irritation changes might arise, and thus easily mask the original 

^ Transactions of the American Ophthalmological Society, 1881. 

^ Archives d'Ophtalmologie, iii. 502. 

^.Transactions of the Ophthalmological Society of the United Kingdom, 1884, p. 152. 

* Gesammten Schriften. 

5 Klinische Monatshlatter, 1863, S. 260. 

6 Proceedings of the Philadelphia County Medical Society, iv. 54. 
' Archives of Ophthalmology and Otology, iii. 70. 

« Klinische Monatsblatter, 1863, S. 259. 

9 Transactions of the American Ophthalmological Society, 1882. 

1" Graefe und Saemisch's Handhuch, 1880, ii. 

" Kecueil d'Ophtalmologie, Septemher, 1888. 



PHOTO. III. 



UNnuE Tortuosity of the Retinal Vessels. (Benson, Transactions of the Ophthalmological Society 

of tlie United Kingdom.) 



OPHTHALMOSCOPY : LOCAL DISEASES. 165 

condition and give rise to confusion in diagnosis. Careful study of the 
case, with special attention to the state of the related tissues, will frequently 
give clue to the proper answer. 

Actual decrease or increase of the normal number of retinal vessels, though 
probably more frequent than has been noticed in ophthalmic writings, should 
always be looked for and considered. Mooren's case^ of complete want of 
retinal vessels in an infant, and Von Graefe's instance" of faulty development 
of the retinal vessels in a young lad, are typical extremes of the former type, 
whilst Benson's^ and Nettleship's* descriptions and pictures of three cases 
in which both the retinal arteries and veins were so extremely tortuous, 
large, and numerous as to give the eye-ground the appearance of com- 
mencing inflammation, well illustrate the latter. The accompanying repro- 
duction shows this condition very well in Mr. Benson's case. Two of the 
reported cases were subjected to traumatism, though whether this consti- 
tuted any causal relationship, or whether the conditions noted were mere 
intraocular expressions of some obscure congenital or neural disturbance, it 
is impossible to determine. 

Anomalous vascular anastomoses, though comparatively infrequent to 
any marked degree, should be carefully studied and noted, so as to prevent 
improper deductions as to result in cases where the usual symptoms of 
disease are changed by collateral circulation through anomalous channels. 
Here vessel-distribution and blood-supply, as elsewhere, are subject to so 
much variation that constant guard must be kept upon the possibility 
of intercommunication. Benson^ gives a drawing showing an anomalous 
distribution of the retinal arteries. There were evidences, however, of 
some past pathological process in the retina. He believes his case unique 
"where three- fourths of the retina received its blood-supply from the in- 
ferior artery, and only one-fourth from the superior artery of the disk." 
Photo. IV., facing page 174, gives an excellent idea of this remarkable 
peculiarity in the venous distribution on the disk as seen in a case by 
Randall,^ who gives an interesting review of venous anomalies upon the 
optic disk. 

Lang and Barrett'' found in forty-eight unselected cases that eight 
(sixteen and seven-tenths per cent.) gave distinct evidences of cilio-reiinal 
vessels. They define the anomalous condition as one in which the vessel 
"dips into the nerve near the margin of the optic disk, and which can be 
seen to arch outward, that is, away from the disk, before it finally disap- 
pears from view." Randall^ reports some very interesting cases, and thinks 

1 Ophthal. Beobfichtungen, 1867, S. 260. 
^ Archiv fiir Ophthalmologie, i. 403. 

* Transactions of the Ophthalmological Societj'- of the United Kingdom, ii. 55. 

* Ibid., ii. 57. a Ibid., 1883, p. 101. 

6 Transactions of the American Ophthalmological Society, 1888, p. 117. 

7 Koyal London Ophthalmic Hospital Keports, January, 1888. 

^ Transactions of the American Ophthalmological Society, iv. 511. 



166 OPHTHALMOSCOPY : LOCAL DISEASES. 

that " about one eye in every five examined shows some form of the condi- 
tion in question." 

Guun details an instance of direct arterio-venous communication of the 
retinal vessels in one eye, the case being complicated with cilio-retinal 
anastomosis in the fellow-eye. Under the title of " Persistent Hyaloid 
Artery," Wells and Liebreich instance a case^ in a sixteen-year-old boy, 
" where, arising from one of the arteries of the disk, was seen a small 
arterial twig running with a slight bend for a short distance into the vitre- 
ous humor, ending in a loop and passing over at once into a vein, which, 
twisting itself like a corkscrew three times around the artery, terminated in 
one of the large central veins." 

Spontaneous pulsation of retinal arteries is quite rare in healthy children, 
and, when present, is generally dependent upon anatomical peculiarities on 
the disk-surface or slight unaccountable changes in the character of intra- 
ocular tension. Venous pulsation, which is readily provoked by increased 
cardiac action through excitement or sudden movements, must not be mis- 
taken for a symptom of pathological change. A few moments' rest will 
ofttimes dissipate it, so that when the fellow-eye is examined all trace of it 
will be lost. 

Though comparatively rare in children, yet irregular isolated thicJcenings 
of all grades of opacity in the vessel-walls are met with, and sometimes of 
sufficient moment to render the contained current invisible. These changes 
are most pronounced upon the main stems and at the vessel-entrance. In 
marked cases, the intervening extents of vessel-wall have their density 
sufficiently increased to change the color of the underlying blood-column, 
and to permit the side walls of the vessel to be distinctly seen as translucent 
bands. 

Areas of glittering reflexes known as " shot-silk opacities," which move 
with every turn of the ophthalmoscope, especially along the course of the 
retinal vessels and in the macular region, are frequently seen. They mani- 
fest themselves only in the young, and gradually disappear after adolescence. 
They are dependent upon a normal increase of connective-tissue elements 
with increased power of reflection. 

TEAUMATISM. 

Rupture of the choroid the result of contrecoup has often been described. 
Immediately following a blow upon the eye, which has not been of suffi- 
cient moment to disfigure the organ externally in the least, there is more or 
less complete loss of sight. Curiously, however, the apparent gravity of the 
accident does not seem to bear any relation to this small, though, of course, 
most important, traumatism. Thus, Mauthner^ relates a case of double rup- 

1 Transactions of the Pathological Society, 1871, p. 222, and A Treatise on the Dis- 
eases of the Eye, 1883 (Amer. ed.), p. 503. 

* Lehrbuch der Ophthalmoscopie, 1868, S. 446. 



OPHTHALMOSCOPY: LOCAL DISEASES. 167 

ture produced by a blow with the fist, whilst Von Ammon's classical case^ 
of breakage of the choroid in the yellow-region spot, with bulging of the 
retina at this point, and no other extravasation within, except a few isolated 
masses between the choroid and sclerotic, as the result of a discharge of 
a musket filled with water, gives us an example of a very unusual method. 
White Cooper's interesting judicial case,^ where an eye was forcibly struck 
by a wooden missile, affords another peculiar mode of accident. 

If attempts be made to examine the interior of the organ by the 
ophthalmoscope, the path of view may be so obstructed with blood-extrava- 
sations as to render this procedure impossible. In such instances either the 
diagnosis is a faulty one, as necessarily showing that the retina must be 
involved in the break so as to allow the passage of blood into the vitreous, 
or else, although the diagnosis is correct, the true condition of break of the 
choroid is complicated by implication of some of the other structures in the 
disturbance, such as involvement of the iris or of the ciliary body. 

Sometimes, however, the amount of blood-extravasation is so trifling 
and limited that the fundus details can be seen directly after the trau- 
matism. If so, the break may generally be found somewhere in the pos- 
terior pole of the organ, appearing as a C- or S-like white stripe which 
is concentric with the temporal border of the optic disk. This break is 
generally bounded by irregular depositions of pigment, whilst small fresh 
hemorrhages may be seen scattered near and over it. Ordinarily the 
fundus otherwise appears normal, though in some instances the neighboring 
area looks disturbed. Sometimes narrow tears may connect with the prin- 
cipal one, or even separated multiple breaks may be noticed. In a few 
days the hemorrhages disappear, leaving their usual characteristic signs. 

Vision, especially central, which at first may be even annihilated upon 
account of the blood-extravasations, gradually partially recovers, to decrease 
again with the ordinary signs of metamorphopsia, etc., as secondary changes 
of cicatrization set in. 

Treatment, which is of but little use, and which is directed towards 
blood-absorption alone, consists in local rest of the organ and leeching, 
combined with the internal administration of alteratives and absorbents. 

Breakage of the retina in association with rupture of the choroid and 
extravasation of blood into the vitreous has often been observed. Shaffher 
reports an interesting case in a boy. Noyes^ details a most curious one in 
a thirteen-year-old girl, where, in addition to the retinal detachment, there 

1 Archiv fiir Ophthalmologie, i. 2, 154. 

2 On Wounds and Injuries of the Eye, 1859, p. 233. In reference to the legal ques- 
tion in this case, it may be of interest to note, in passing, an instance which came under the 
writer's care some time ago, where a fortunate (or possibly unfortunate) attorney in a suit 
for damages was struck in the left eye by the fist of the defendant. Careful examination 
revealed a large choroidal break in the macular region, with all the characteristic sub- 
jective symptoms. Medical testimony, expressed very briefly and to the point, had the 
result of bringing in the verdict of " mayhem," with the accompanying penalty. 

^ Transactions of the American Ophthalmological Society, 1871, p. 128. 



168 OPHTHALMOSCOPY : LOCAL DISEASES. 

was a laceration of the membrane at the macula lutea. In nearly all of 
these cases there is no evident external lesion. The prognosis is dependent 
upon the position and the amount of the disturbance, though, unfortunately, 
by reason of the Gontrecoup, as just shown, the break is generally situated 
in or near the macular region. Xo treatment, except rest and quiet, with 
the possible use of alteratives, can be advised. 

In alnaost every case of injury to the retina from a foreign body lohich 
has gained access to the interior of the globe, the associated results are so severe 
that it is impossible to decide the position of the offending material. Here, 
if the substance be iron or steel, the magnetized needle of Pooley will be of 
service in its detection, and if the case be seen early, the electro-magnet 
may be of use in extraction. If the particle be of any other nature, such 
as stone, glass, etc., operative attempts should also be made for its removal, 
provided there be any possibility of success. As an example of the possible 
freedom of the organ at times from the series of dangerous after-symptoms 
usually seen in such instances, the writer has in mind a case seen in consul- 
tation with Dr. James Tyson, in May, 1888, of a lad in vrhose left retina 
a small sliver of steel became embedded, the passage of the stroke being 
through the cornea, the lens, and the vitreous. Fortunately, the foreign 
body escaped striking the iris or the ciliary region, and in consequence, with 
the exception of a slowly-forming cataract, the eye has remained perfectly 
quiet and painless from the date of the accident to the present writing, 
nearly two years. Although many cases could be quoted where foreign 
bodies have become encapsulated in the membrane and remained quiescent 
for long jicriods of time, yet active inflammation, resulting in destructive 
panophthalmitis, is so prone to occur, that it is best to give a guarded prog- 
nosis in every case. If possible, and most certainly if under the immediate 
care and control of a competent observer, enucleation or evisceration should 
be postponed until the child's skull has sufiiciently developed to prevent 
facial asymmetry. If the slightest well-grounded suspicion of involvement 
of the opposite organ be entertained, it is best to sacrifice all question of 
cosmetics and get rid of dangerous tissues.^ 

Detachment of the retina may occur from bl'ows, as in Brailey's case ^ of 
a twelve-year-old boy who receiv^ed a blow upon the eye with a stone ; from 
penetrating wounds of the eyeball, posterior to the ora serrata ; or as a 
sequel of subretinal hemorrhage, as was most probably the cause in Snell's 
case ^ in an eleven-year-old boy. It has also been seen as one of the sequelse 
of progressive inflammation and stretching of the ocular tunics, as, for 
instance, in malignant myopia, or it may even appear as a symptom of cir- 
cumscribed malignant disease of the choroid, as shown by Poncet.* The 
theories of its pathogenesis, which are manifold, can be best studied in the 

1 See ISToyes, A Text-Book on Diseases of the Eye, 1890, p. 577, on the same subject. 

2 Transactions of the Ophthahnological Society of the United Kingdom, y. 11, 

3 Ibid., vi. 38. 

4 Quoted by Noyes, A Text-Book on Diseases of the Eye, 1890, p. 544, 



OPHTHALMOSCOPY : LOCAL DISEASES. 169 

Doble work of Nordenson/ iu which he sustains Leber's belief of shrinkage 
of the vitreous with traction, — a theory supported by De Wecker ^ and con- 
troverted by Boucheron and Abadie.'^ The diagnosis, which is very easy, 
is made in most instances by direct evidence Avith the ophthahnoscope, iu 
association with corresponding loss of the visual field, and diminished ten- 
sion. The prognosis is very unfavorable. Enjoined rest, the best of nour- 
ishment, with remedial agents such as pilocarpine to promote absorption, 
can be resorted to, and if, as is almost universally the case, no good arises, 
operative procedure to dislodge the fluid and produce localized plastic 
formation may be tried. Treatment, however, is usually of no avail. 

Choroidal detachment is extremely rare. Noyes,^ after a long and large 
experience, has never had a case to come under his notice. In over twenty 
thousand new cases of eye-disease personally seen by the present writer, 
he has failed to find a single instance. Cases, however, have been spoken 
of: thus. Von Graefe^ describes such a case, and Iwanoff ^ has been so fortu- 
nate as to be able to study an eye affected with this condition. Ophthalmo- 
scopically, an isolated area of choroid can be seen protruding markedly 
into the vitreous, the bulging portion being fixed and immobile. Its sur- 
face is uninterruptedly traversed by the retinal vessels. Should the under- 
lying material be serous in character, the bulge may be somewhat pallid ; 
whilst should it be blood, the area will be dark-colored. As the condition 
advances, intraocular tension falls, inflammatory symptoms set in, and pan- 
ophthalmitis with phthisis bulbi ensues, — these sequelse serving to distin- 
guish it from neoplastic formation. Treatment is of no practical' value, 
although aspiration or drainage in the early stages may be tried. 

In a peculiar variety of cases, where the traumatism has avoided the 
eye itself and acted upon the bony walls of the orbit, there is often a sub- 
sequent involvement of the optic nerve and retina without early ophthal- 
moscopic evidence of intraocular disturbance. The after-changes which 
come on are optic neuritis with consecutive atrophy, retinitis, venous dis- 
tention, hemorrhages, etc., which suggest either direct pressure upon the 
optic nerve, as reported by Knapp, interference with the passage of blood 
in the central retinal artery, as suggested by Noyes,^ or fracture of the 
bony optic canal with extravasation of blood into the sheaths of the optic 
nerve, as shown by Von Holden.^ Pigment-deposits upon the disk, from 
degenerative changes in the blood which has been extravasated from the 
intravaginal spaces in the optic nerve, have been seen. In a few cases no 
ophthalmoscopic signs have been observed. In this last grouping, Schweig- 

1 Die Netzhautablosung, "Wiesbaden, 1887. 

2 Annales d'Oculistique, March, 1888. ^ Ibid. 
* A Text-Book on Diseases of the Ej-e, 1890, p. 586. 

^ Archiv fiir Ophthahnologie, iv. 2, 226. 

6 Ibid., xi. 1, 191. 

' A Treatise on Diseases of the Eye, 1881, p. 350. 

^ Berlin, Graefe und Saemisch, vi. 588. 



1 70 OPHTHALMOSCOPY : LOCAL DISEASES. 

ger's saying/ that " the anatomical condition of the nerve-trunk in neuritis 
has been examined often enough to prove that changes not visible by the 
ophthalmoscope may play an important part in causing the disturbances 
of vision/' must be borne in mind. If the nerve be injured sufficiently 
forward to include the central artery of the retina, the ophthalmoscopic 
signs simulate those of embolism. Pagenstecher cites the history of a very 
interesting case in a young girl. Treatment is either purely surgical or to 
be directed against the special dyscrasia or condition, combined with ocular 
rest. 

A case of metamorphopsia following a blow on the eye has been described 
by Aub/ which can probably be attributed to a low grade of inflammatory 
change in the retina in the region of the macula lutea, causing a disloca- 
tion of the position of the rods and cones. The writer has seen two cases 
of traumatism without apparent external lesion, except an irregular thick- 
ening of the corneal epithelium, where the ophthalmoscope showed a cir- 
cumscribed area of disturbance in the choroid and retina between the 
macula and the disk ; this condition of the fundus rapidly disappearing in 
a few days' time upon protecting the eye from light and undue exposure. 
Jackson ^ gives two chromo-lithographs of a similar though more marked 
condition seen in the eye of an adult. 

Damaging effect upon the retina from exposure to direct solar rays has 
been observed. Central scotoma is the initial symptom. Examination of 
the fundus shows a bright whitish spot at the macula lutea, surrounded by a 
red rirri. The permanency of damage to the tissues is in direct relation to 
the amount of primary injury. In Deutschmann's experiments upon the 
retina there were changes in the vascular walls, with coagulation of retinal 
albumen. Exalted sensibility of the retina from the same cause has been 
noted. In three patients who were unduly exposed to direct solar rays, 
Magawly* has noticed central scotomata for red with reduction of vision 
to one-fourth of normal. The symptoms soon ceased upon placing the pa- 
tients in the dark and protecting their intraocular tissues by dark glasses. 
Lubinsky^ has seen thirty cases of suffering from undue exposure to the 
electric light. Besides daily exacerbation of photophobia and lachrymation, 
the ophthalmoscope revealed a slight congestion of the optic nerve tip. 
Maklakoff ^ has studied the personal effects of the " voltaic light" upou the 
eyes. He concludes that such a light nearly always acts by its chemical 
properties. 

Ametropia as found in abused and stretching eyes may give all the 
evidences of low choroiditis with retinal disturbance, and even optic nerve 

1 Hand-Book of Ophthalmology, 1878, p. 484. 

2 Archives of Ophthalmology and Otology, ii. 173. 

^ Transactions of the American Ophthalmological Society, 1888, p. 68. 

* Zeitschrift fiir Schulgesundheitspflege, No. 4, 1889. 

"S Wjestnik Ophtalmologie, May, 1889. 

6 Moniteur d'Ophtalmologie, January, 1889. 



OPHTHALMOSCOPY : LOCAL DISEASES. 171 

swelling, without any subjective acknowledgment of the intraocular con- 
dition. 

Direct implication of the optic nerve vjith extension to the retina from other 
inflammatory processes in the orbit, such as cellulitis, periosteal disease, 
tumor, etc., may occur, where either pressure from the morbific material 
causes rapid loss of sight followed by atrophic changes in the disk, as 
described by Allbutt, or invasion of the products of the disease into the tis- 
sues of the nerve itself may give rise to a similar ophthalmoscopic sign. 
Here, at first, rapid monocular failure of vision, with but little congestion 
of the disk and a doubtful haze of the retina around and near the macular 
region, is the symptom usually noted. With this failure of sight there is 
generally associated periorbital neuralgia, with pain upon motion of the 
globe or v/heu decided palpation of the organ is made. In view of Hock's^ 
belief that the position of pressure or the localized retro-ocular neuritis 
may be determined by the direction of motion giving the greatest pain, 
it would be well to apply this diagnostic procedure to a careful test in all 
suspected cases. If the case progresses, paralyses of contiguous nerve-ter- 
minals may occur, atrophic changes in the disk, with increasing "fog" 
before the eyes, central scotomata, and rapidly-lessening field of vision and 
diminution of central color perception take place, until at last atrophy with 
blindness ensues. Nettleship^ details some instructive cases in adults. 
Again, an intraorbital point of infection may produce a descending neuritis 
with all the ordinary subjective and objective signs of inflammation. The 
ophthalmoscopic picture in these cases is discriminated by the concomitant 
extraocular symptoms from similar fundus changes that may appear in 
cases of cerebral disease, or which are seen in the course of some general 
dyscrasia. In fact, in all cases of monocular neuritis suspicion should most 
■ certainly point towards local disturbance. In every case of this character 
that the writer has seen there has been some local trouble either in the orbit 
itself or in the cranial cavity just at the optic foramen to account for the 
neural disturbance. Of course it will be readily understood that a local- 
ized inflammatory condition of the tissues of the orbit can easily appear 
as symptomatic of some general dyscrasia. Here the intraocular condi- 
tions are identical. It must be remembered that mere stretching of the 
intraorbital portion of the optic nerve may also give rise to deterioration 
of vision. Ayres's cases,^ in which there was extravasation of blood in 
the orbit, causing both pressure and stretching, furnish good illustration. 
True orbital aneurism may be productive of the same condition. Her- 
mann Pagenstecher * relates an almost unique instance of direct injury 
of the optic nerve, with rupture of the central retinal artery and corre- 
sponding vein, by an irou rod. The patient, a girl of twelve years, was 

^ Centralblatt fiir prakt. Augenheilkunde, iv., 1884. 

2 The Lancet, 1880, i. 76G. 

3 Archives of Ophthalmology, 1881, p. 42. 
* Archiv fiir Ophthulmologie, xv. 1, 223. 



172 OPHTHALMOSCOPY : LOCAL DISEASES. 

completely blind. Ophthahiioscopically, the optic disk could not Ije seen, 
on account of a large, dense, glistening effusion, apparently several times 
greater in area than the nerve-head itself. A single retinal vessel was 
alone visible. In several days' time absorption took place, which revealed 
the disk-surface, wliilst collateral retinal circulation ensued. Hocken^ 
quotes from ^Mackenzie an historical case related by Horstius in the seven- 
teenth century, ^vhere a fourteen-year-old boy was rendered blind, without 
any perceptible ocular lesion, by an arrow-tip which had been driven into 
the orbit. The foreign body remained in situ for more than thirty years. 
The present writer remembers an instructive case of retro-bulbar breakage 
of the optic nerve anterior to the entrance of the central- retinal artery, 
which he saw in his service at St. Mary's Hospital. The wound, Avhich 
was self-inflicted, was caused by the upward entrance of a ]N^o, 22 pistol- 
cartridge, which passed through the lower outer part of the right orbit into 
the cranial cavity. Eight hours after the injury, the optic nerve entrance 
seemed whitish, swollen, and puifed, whilst the portion of the retina that 
could be seen peripherally appeared utterly devoid of capillarity. In the 
few days that remained for study, no changes, except a slight stibsidence 
of the disk-swelling, with a gradually-increasing haze of the outlying retina, 
took place. Retinal circulation never reappeared. The cornea became 
hazy and dry, the conjunctiva seemingly thickened and became slightly 
covered with excreta. Death took place in four days after the injury. 

Tu::iiOES OF the choroid, optic xeeye, axd eetixa. 

Tumors of the Choroid. — Although it is well known that almost all 
choroidal tumors are sarcomatous in character, whicli form of neoplasm is 
eminently one of adult life,^ yet it is deemed of sufficient importance not 
only to speak of the occurrence of choroidal tumor during childhood, as a 
disease which should be carefully differentiated from subretinal effusion, 
with which it has been unfortunately confounded, but also to give a short 
exposition of its characteristics, by which recognition of its presence may 
be obtained in time to effect a ready and speedy removal of a nidus of 
general infection. The disease itself is comparatively rare in Germany, — 
one in fifteen hundred cases, — as Fuchs^ tells us, with a still lower propor- 
tion — one to two thousand two hundred and eighteen cases — in the English 
hospitals, as shown by Berry .'^ 

Of slow growth, with a Ijroad foundation, and generally first appearing 
between the disk and the macula, it gradually pushes the retina forward 
into the vitreous. Frequently this elevation is surrounded by a serous 
effusion, though this, if carefully looked through, is generally insufficient 

^ A Treatise on Amaurosis, 1842, p. 96. 

2 Puchs's (loc. cit.) statistics give but eleven under ten years, and twenty-seven under 
twenty yeai^ of age, out of two hundred and fifty cases. 

3 Das Sarcom des Uveal-Tractus, 1882. 
* Diseases of the Eye, 1889, p. 348. 



OPHTHALMOSCOPY : LOCAL DISEASES. 173 

to hide the brownish mass beneath.^ OfteD this protuberance can be seen 
covered by a faint and irregular congeries of vessels, situated upon a deeper 
level than the overlying retinal stems. This stage of the disease is known 
by Knapp ^ as the first — the " quiescent or non-irritative" — stage. Should 
the neoplastic formation be situated nearer the equator of the eye, towards 
the ciliary region, the second stage, or the " inflammatory" (Knapp), much 
sooner appears. Here glaucomatous symptoms arise, tension increases, 
ocular and ciliary neuralgia ensue, the lens opacifies, the anterior veins 
enlarge, the cornea becomes ansesthetic, and the anterior chamber is anni- 
hilated : in fact, all the symptoms of increased pressure are present. Oph- 
thalmoscopic examination now becomes impossible. In various grades of 
objective change, some in one case more pronounced than in another, the 
second stage gradually ceases, and the "extraocular stage" (Knapp) is 
reached. The mass now perforates the globe and rapidly increases and 
ulcerates. The external appendages and the surrounding tissues soon, 
become involved, whilst the pain recommences, until at last the " metastatic 
stage" (Knapp) is reached. Finally the case leads to fatal termination. 

As our study in this section is limited to the ophthalmoscopic diagnosis 
of this insidious and secret disease, it will be only necessary, from what has 
been said before, to give a few differential points which denote its presence. 
Except in the very rare form of leuco-sarcoma, the most incompetent observer 
can hardly fail to distinguish it from glioma of the retina : moreover, as the 
treatment is the same in these two diseases, no great therapeutic error can 
arise. With choroidal tuberculosis the problem is more difficult. In fact, 
this form of choroidal disease has been mistaken for sarcoma ; yet here the 
general type of the oatient, the ordinary relative positions of the two varieties 
of growths, the usual greater multiplicity and smaller size of the tubers, 
the color and the long persistence of the sarcomatous growth, with its usual 
increasing pressure-signs, all serve to separate the diagnosis of one disease 
from that of the other. Complicated as choroidal tumor is almost from the 
first with retinal detachment, the observer must be well trained, or the sub- 
retinal effusion be very transparent, to enable him to differentiate it from 
simple retinal detachment. Later, however, as the choroidal mass grows 
and forces the liquid and solid contents of the globe against the various 
canals which serve to maintain normal equilibrium between fluid and solid, 
the pathognomonic pressure-symptoms of new growth appear, and intra- 
ocular tension increases, with all its dire consequences ; whereas in retinal 
detachment intraocular tension, as is well known, gradually lessens. ]\Iore- 
over, at first some value may be set upon the almost absolute immobility 
of the overlying retina, as well as upon its comparative smoothness. 

In children the subjective symptoms at first are seldom, if ever, brought 

1 The fact that Hirschberg (Archiv fiir Ophthahnologie, xvi. 304) reports an instance 
of leuco-sarcoma in a girl of twelve years, should render us careful in this differential 
point. 

2 Die Intraocularen Geschwiilste, 1868. 



174 OPHTHALMOSCOPY: LOCAL DISEASES. 

to attention, and it is only as the second and later stages are reached that 
the disease is recognized. Prognosis, as a rule, is bad, whilst treatment 
resolves itself into an immediate enucleation, even though vision be com- 
paratively good. 

Granuloma, angiomata, and enchondroma of the choroid have all been 
seen. The cases have almost universally been found among adults. 

Tumors of the optic nerve, comparatively rare themselves, are more fre- 
quent in childhood than in adult life, Sym having found sixty per cent, of 
sixty-nine cases in patients under twenty years of age. They appear both 
in the intraocular ending and in the nerve during its passage through the 
orbit. The most frequent forms are sarcomata and gliomata, with their 
related types, and neuromata, as in Perls's case. Sutpheu^ notes an extraor- 
dinarily large-sized and peculiarly-shaped sarcomatous growth of the small- 
cell variety. Syphilitic gummata are said also to have been seen. The 
left nerve seems to be the one the more frequently attacked. Von Graefe 
gives a case^ in which, ophthalmoscopically, there could be seen a swell- 
ing confined to the nasal half of the disk, with dilatation and tortuosity 
of the retinal veins and contraction of the arteries from a myxoma of the 
nerve posterior to the globe, and Lawson^ gives the clinical history of a 
case with the pathological report' of a post-ocular sarcoma of the optic 
nerve undergoing myxomatous degeneration in a twelve-year-old boy, who 
for months had gradually lost vision, associated with steadily-increasing 
proptosis. These two instances may be cited as very interesting examples 
of such growths. The accompanying phototypes give excellent ideas of 
the appearance of the tumor in the latter case, both before and after section. 
Frothingham* gives the histories and the results of examination by the 
microscope of his cases of round-celled sarcomata in children. Ayres^ 
records a most careful study of a case of sarcoma of the small round-celled 
variety in a twelve-year-old boy. In view of Michel's observation^ of 
hyperplasia of the intracranial portion of the optic nerve, and the chiasma 
itself, in a case of elephantiasis in a man, it would be of interest and value 
to have a series of careful ophthalmoscopic examinations made by those who 
are favorably situated among a large number of infected children (or adults), 
in order to determine the exact nature of the resultant physical changes 
and the character of the functional disturbance produced. 

Diagnosis is, in the main, dependent upon the following symptoms : 
progressive outward, upward, and forward, and sometimes downward, pro- 
trusion of the eyeball ; rapid loss of vision, with frequent ophthalmoscopic 
signs of infiltration ; pressure and atrophy ; long continuance of seemingly 

^ Transactions of the American Ophthalmological Society, 1889, p. 45L 

2 Archiv fiir Ophtlialmologie, x. 1, 193. 

^ Koyal London Ophthalmic Hospital Eeports, 1888, p. 1. 

* Ayres, Journal of the American Medical Association, Decemher 10, 1887. 

s Loc. cit., March 8, 1890. 

fi Lehrbuch der Aueenheilkunde, S. 642. 



PHOTO. IV. 




l?md'>*/i^i:l 



Anomalous Venous Distribution on the Disk. (Randall, Transactions of the American 
Ophtlialmological Society, 1888.) 



FlQ. 1. 



PHOTO, y. 



Fig. 2. 








Post-Ocular Sarcoma of the Optic Nerve. (Lawson, Royal London Ophthalmic Hospital Reports, 

1888.) 



OPHTHALMOSCOPY: LOCAL DISEASES. 175 

free ocular motion ; and, generally, complete absence of pain. Treatment in 
every instance should consist in early extirpation of the entire tumor-mass. 
If the eyeball is not aifected, the nerve itself, as Knapp suggests, may be 
excised. This rule is especially applicable to children, though care should 
be taken to watch carefully the slightest tendency to recurrence from some 
infiltrated nerv^e-tissue which may be inadvertently left. It should be 
remembered, however, that fatal septic meningitis has several times taken 
place in cases where the eyeball has been allowed to remain, and that even 
where such brilliant success has followed as in Schiess-Gemusseus's case,^ 
instances have been reported where suppurative panophthalmitis has fol- 
lowed the traumatism. 

Glioma of the retina, as Virchow^ terms it, is almost essentially a 
disease of infancy and childhood, rarely, if ever, appearing in the adult. 
Without entering into the various disputes as to the initial point of infil- 
tration, and avoiding any discussion as to its exact pathological nature, it 
will be sufficient to state that the bulk of opinion shows that it is practically 
identical with small round-celled sarcoma, and that, although it may begin 
in any of the retinal layers, it most frequently first manifests itself in the 
" external granular." In regard to its etiology, Brailey^ is of the opinion 
that retinal glioma runs a much slow'er course than is commonly supposed, 
and fancies " that it always takes its rise within the period of intra-uterine 
life." 

During the early stages there are no symptoms visible to the naked eye, 
but at a later period a peculiar whitish-yellow reflex, often metallic in tint, 
just back of a partially-dilated pupil, manifests itself, giving the appearance 
of the " amaurotic cat's eye" of Beer. Should the case have been examined 
earlier, as has been done by Von Graefe,^ numerous small w^iite swellings 
would have been seen in one of the granular layers (or in the fibre layer) 
of the retina. These would soon have increased in size and their surfaces 
coalesced. Should the disease have commenced in the granular layer, the 
retina itself would have become detached in areas at its outer portion, 
giving rise to circumscribed masses of protuberant vascular vegetations 
containing more or less broad, smooth surfaces. If not, the massings 
would generally have projected into the vitreous, and have carried the im- 
plicated portions of the retina with them before the membrane had become 
detached. 

It is at this time the case is generally seen. The tension of the globe 
is perceptibly increased. The intraocular changes continue, secondary foci 
appear, and more intense pressure-symptoms ensue. The lens and the iris 
are pushed against the cornea, the lens rapidly degenerates, the pupil be- 
comes dilated and immobile, and the cornea is ^' steamed" and anaesthetic : 

1 Archiv fiir Ophthalmologie, xxxiv. 

2 Die Krankhaften Geschwiilste, ii. 1, 159. 

^ Transactions of the Ophthalmological Society of the United Kingdom, 1885, p. 62. 
* Archiv fiir Ophthalmologie, xvi. 129. 



176 ophthalmoscopy: local diseases. 

in fact, all the symptoms which are found in acute attacks of glaucoma 
ensue. Often, at this point, suppurative inflammation takes place in the 
interior of the globe, and the eye soon becomes atrophic and degenerated, 
allowing the neoplasm to escape and invade the adjacent structures. If 
not, the tumor gradually seeks its way out by either creeping along the 
nerve-tissues or actually breaking the ocular walls. Once free, it rapidly 
becomes a projecting mass of deep red tint, constantly oozing blood and 
secreting pus. New foci form and coalesce into large, irregular masses. 
The infiltration passes up into the brain-cavity, the orbital walls become 
involved, and metastases occur, until, at last, from exhaustion, or from some 
intercurrent complication, the patient is relieved by death. 

In spite of reported cases of long remission, recurrences^ and metas- 
tases are so frequent and so increasingly formidable that prognosis is truly 
grave. 

Treatment. — If the neoplasm be even extremely minute and confined 
to the interior of the globe, immediate enucleation, taking care to excise 
the optic nerv'-e as far back as possible, should be practised. After the 
removal of the eyeball, its exterior should be carefully studied, as Bull- 
has shown that small secondary tumors on the outer side of the sclera 
may exist without any visible microscopic connection with the intraocular 
growth. If the orbit be invaded in the least, or if the globe show marked 
signs of internal inflammatory reaction without breakage, total evacuation 
of the entire orbital contents should be done. If double gliomata exist, 
double enucleation must be resorted to, or exenteration if necessary.^ In 
all such cases, however, we can do no more than repeat Frost's question, 
"Are there any cases in which life has been actually preserved by the 
excision of both eyes?"* 

Sarcoma of the retina in the young is practically unique, although there 
can be but little doubt of its possible existence. It generally results by 
extension from the choroid, as in Williams and Ayres's case of a twelve- year- 
old girl, where Knapp ^ after careful examination found that the choroidal 
neoplasm had extended to the retina by direct propagatiou. Euucleation 
of the infected organ should be advised and immediately done, and the 
child's parents warned of probable distant metastases. 

Tubercles in the retina will be considered under Tuberculosis. 

1 Noyes (A Text-Book on the Diseases of the Eye, 1890, p. 583) says, " a single case is 
given in which the patient survived after the removal of a secondary tumor."' 

2 Wells, A Treatise on Diseases of the Eye, 1883, p. 550. 

3 Dujardin's repoi't of a case of monocular glioma in which four weeks after the enuclea- 
tion of the affected eye the fellow-eye, which appeared perfectly normal, both externally 
and ophthalmoscopically, became totally blind, is interesting as showing that the neoplasm 
had most probably travelled back to the optic nerve of the affected organ, and, upon reach- 
ing the chiasm, had destroyed the related tissues of the sound eye. 

* Transactions of the Ophthalmological Society of the United Kingdom, v. 64. 
s Archives of Ophthalmology and Otology, 1874, p. 241. 



OPHTHALMOSCOPY : SYMPTOMATIC DISOKDERS. 177 



11. SYMPTOMATIC DISORDEES. 

LESIOXS DEPENDENT UPON DISORDEKS OF THE CIECULATOEY 

SYSTEM. 

Vascular disease in the young is not so prone to give ophthalmoscopic 
pictures of changed and altered retinal circulation as it is in older eyes, 
which are less elastic and in which the tissues at large have not the same 
powers of ready compensatory action. Even in extreme cases intraocular 
tension so carefully protects the retinal vessel- walls as to allow very little 
or no departure from the normal. 

In congenital cyanosis the retinal veins have been found greatly dilated, 
giving, according to Gowers/ proof that the distention of the venous radi- 
cles contributes to the general cyanotic tint of the child. Stangloneier ^ 
reports the occurrence of retinal hemorrhage immediately preceding death, 
and Leber ^ has seen cases where both the retinal arteries and the retinal 
veins were distended. 

Acquired valvular disease may show itself in the retina by marked 
changes in the retinal circulation, and, in fact, these changes have con- 
tributed to the diagnosis of the condition. 

In some cases of aortic insufficiency with regnrgitation, Quincke,* con- 
firmed by Becker/ has shown that there is an alternate systolic flush and 
diastolic paling of the disk, comparable with the capillary pulsation seen 
through the finger-nails of such subjects. In other cases the intraocular 
pulsation may be seen in the larger veins and arteries of the retina. 

Any condition, such as mitral disease, causing pulmonary obstruction 
and producing general venous engorgement must naturally give rise to dis- 
tention with apparent increase, and tortuosity, of the retinal veins. Extreme 
dilatation of the right heart may cause similar appearances. Choroidal 
hemorrhage has been noted by Westphal ® in what is termed malignant en- 
docarditis. Generally, however, such cases are found in the female adult 
and seem to be associated with the post-puerperal period. Valvular disease 
of the heart, especially where there is a tendency to the formation of blood- 
clots and vegetations, is sometimes productive of embolism of the central 
artery of the retina, or of one of its branches within the eye. It can, as 
Gowers says, occur at any age. Warren Tay ^ has had the good fortune to 
see an infant of twelve months that, without definite history, presented an 
appearance in each macular region which closely simulated embolism of 

1 Medical Ophthalmoscopy, 1882, p. 200. 

2 Inaug. Diss., "Wiirzburg, 1878. 

3 Graefe und Saemisch, v. 524. 

* Berliner Klinische Wochenschrift, 1868. 
^ Ai'chiv fiir Ophthalmologie, xviii. 207. 
6 Archiv fiir Psychiatric, ix. 3, 389. 

' Transactions of the Ophthalmological Society of the United Kingdom, 1881, p. 55. 
Vol. IV.— 12 



1 78 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

the central artery of the retina. Four months later he notes that although 
the macular changes remain the same, yet " the disks are now undoubtedly 
becoming atrophic.^' Later/ he notes a third instance in the same family. 

If the embolus should become lodged in the main trunk, the child will 
complain of a sudden loss of vision, — generally upon the left side. If 
one of the minor stems be involved, the loss of vision may not be observed. 
Should the former case be seen immediately after the accident, the nerve 
will appear pallid, the arteries greatly contracted, and either empty or con- 
taining very thin stationary columns of light blood ; the veins will appear 
reduced in size, tapering as they enter the affected region, and holding cur- 
rents of immobile dark blood, whilst no visible pulsation in the retinal 
vessels can be produced by artificial increase of intraocular tension from 
pressure of the finger upon the globe. In a few hours the disk-edges dis- 
appear beneath the retinal elements, which have become transformed into a 
large, irregular area of oedematous and semi-opaque swelling extending 
beyond the macular region. By reason of the thinness of the membrane in 
the region of the yellow spot, the choroid is seen more plainly at this place, 
and gives the characteristic cherry-red spot. This spot, as a rule, is sur- 
rounded by a corona of small vessels. Beaded columns of blood now begin 
to pass through the most patulous veins, whilst the arterial currents become 
re-established in the same way. The calibre of the veins increases. Small 
hemorrhages occur, and remains of old hemorrhages appear. The oedema, 
which may have become greater, gradually lessens, until at last the disk- 
edges again appear, the cherry-colored macule fades entirely, and the original 
retinal level is reached. If, however, the process continues, atrophy of the 
nerve ensues, and degenerative changes in the affected region take place, 
until the eye, if not entirely blind, is rendered useless for all practical pur- 
poses. The accompanying reproduction from a doubtful case of Jaeger^ 
gives an excellent idea of the condition during the height of the attack. 

If the embolus be confined to one of the smaller twigs, the localized 
results may be of such little moment as not to interfere with useful vision. 

Prognosis is bad in direct proportion to the size and situation of the 
embolic mass. It may be interesting to note in this connection that Benson 
reports one case ^ in which the presence of a cilio-retinal artery offered suffi- 
cient collateral circulation to preserve good central vision, whilst the periph- 
eral field entirely disappeared. Massage to promote re-establishment of 
circulation has been tried, and, although as yet with no practical value 
except in a few instances, is worthy of repetition. Absorbents, or drugs 
which have effect upon the size of vessel-calibre, might be tried. The attack 
should act as a warning, and the parents should have certain hygienic 
measures as to the management of the child and a system of dietetics as 
to its care given to them towards the prevention of the danger of the lodge- 

^ Loc. cit., iv. 158. 

2 Beitrage zur Pathologie des Auges, Plate XXX. 

^ Eoyal London Ophthalmic Hospital Keports, x. 3, 336. 



PHOTO. VI. 




Embolism of the Central Artery of the Retina. (Jaeger, Beitrage zur Pathologie des 

Auges, Plate XXX.) 



PHOTO. VII. 




Optic Neuritis of General Anaemia. (Gowers, Medical Ophthalmoscopy, 1882.) 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 179 

meiit of other emboli in more serious places, such as the brain ; whilst the 
physician should exercise due care that the rules made are faithfully carried 
out. 

In two cases of cardiac disease, where sudden blindness, resolving itself 
into a temporary central scotoma, followed by a return to normal vision, 
was associated with a peculiar retinal haze and congestion extending from 
the macular region to the disk, Knapp ^ ascribed the intraocular appearances 
to embolis^n of the choroidal vessels. Both subjective and objective symptoms 
ultimately disappeared. 

Diseased condition of the coats of the vessels may either directly or in- 
directly give rise to thrombosis of the central retinal artery. No authentic 
description of its early ophthalmoscopic appearance in children has, so far 
as the writer is aware, been made. The probable primary change would be 
decreased size of the retinal ai^tery and its branches. Unfortunately, from 
the usual character of the vessel-disease, canalization of the thrombus can 
hardly be expected, and atrophic changes in the globe w^ould soon occur and 
destroy the organ, either partially, as in Virchow's ^ case, or totally, as in 
Gowers's,^ 

Phlebitis from mitral and aortic disease may produce thrombosis of the 
central retinal vein in the young. Local disturbance in some part of the 
membrane has produced thrombi in the walls of the retinal veins. The 
ophthalmoscopic appearances are somewhat like those of embolism, but there 
are said to be certain distinctive differences between the two affections. In 
thrombosis the arteries are never empty ; the veins, although, as a general 
rule, enormously dilated, may be normal in size; hemorrhages are much 
more numerous ; venous pulsation can sometimes be provoked, and the 
vitreous may become opaque. Vision, as a rule, is never completely lost, 
and improvement may take place. 

It must be conceded by those who have had much opportunity for ob- 
servation that differential diagnosis is often exceedingly difficult, and may, 
indeed, prove impossible, on account of association of the two conditions. 

The treatment is practically the same as that for embolism. 

Choroiditis of a purulent type has sometimes been seen as one of the 
sequelae of emboli in the choroidal arteries, or even of thrombi in the oph- 
thalmic veins. Although of infrequent occurrence in children, yet cases 
have been observed. The entire grouping of panophthalmitis signs, so 
common after traumatism, are repeated in all their severity, whilst the 
termination of the case, as is well known, is almost sure to be absolute 
blindness, with destructive and atrophic degeneration of the globe. 

So-called ischsemia of the retina is quite rare. Von Graefe's^ early 
description of a case in a girl of five and a half years, who suddenly 

1 Archiv fiir Ophthalmol ogie, xiv. 
^ Archiv fiir Path. Anatomie, x. 159. 
3 Medical Ophthalmoscopy, 1882, p. 29. 
* Archiv fiir Ophthalmologie, viii. 1, 143. 



180 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

became blind in both eyes, is of clinical interest. The optic disks were 
found slightly hazy, the retinal arteries greatly contracted, and the reti- 
nal veins enlarged and tortuous. Intraocular tension in each eye seemed 
normal. The child's pulse being quick, weak, and thread-like, — indicating 
feeble heart-action, — he was led to believe that the blood-current force was 
unable to overcome the ordinary tension of the globe. This view induced 
him to lower intraocular tension. This was done by puncture of the cornea, 
with evacuation of the aqueous humor, in one eye, and an iridectomy upon 
the fellow-eye, just as is done in glaucoma. The effects were marvellous. 
Sight speedily returned to normal, and all the ophthalmoscopic changes dis- 
appeared. The condition of the veins in these cases would lead the writer 
to think that the true cause is most probably compression of the central 
artery by hemorrhage in the nerve-substance, or is one of the results of a 
small thrombus which has become lodged in the corresponding vein during 
the passage of the vessel through the nerve posterior to the globe. The 
whole subject, however, must remain sub judice until more accurate data 
are obtained. 

Endocarditis,^ degenerative changes in the vascular walls from various 
dyscrasise, hereditary conditions, as seen in cases of haemophilia, etc., may 
all be productive of hemorrhage into the retina. The ophthalmoscopic 
appearances are typical. There is very little or no inflammatory change 
visible. Areas of extravasated blood, especially near the bifurcation of the 
larger vessels, show themselves, indicating, by their peculiar shapes, the 
structure of the retinal layer in Avhich they have occurred. In a few weeks' 
time they gradually fade, leaving, in many instances, either faint pigment- 
massings or spots of disturbed choroid and degenerate retina. 

The prognosis is directly proportionate to the position, the number, 
and the size of the hemorrhao;es. 

Treatment. — Local measures, independent of rest of the eye, are of but 
little use. The cause must be sought, and measures directed towards it, 
taking care to keep the patient as quiet as possible, the emunctories well 
open, and the digestion in a good condition. 

Eales^ has described some cases of recurrent retinal hemorrhage asso- 
ciated with epistaxis and constipation. They appear at or just after ado- 
lescence. All the cases seen were in males. The extravasation generally 
comes on during a paroxysm of coughing or laughing, but may ensue with- 
out any assignable cause. I^o evil results seem to follow, the blood grad- 
ually clearing away and allowing a clear view of the fundus. One pecu- 
liarity noticed was a tendency to tortuosity of the peripheral portions of 
the retinal veins. The writer has been so fortunate as to see one of the 

1 Chronic endocarditis will be spoken of more fully under " Chronic Bright's Dis- 
ease," to be found in a succeeding section : this has been done not only to keep the 
subject-matter together for associated reference, but also because it will most probably be 
sought for in this position. 

2 Birmingham Medical Review, July, 1880, p. 262. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 181 

cases mentioned in Mr. Eales's paper, and found direct evidence of hemor- 
rhagic extravasation into the sheaths of one of the retinal arteries, whilst 
the patient presented unmistakable signs of hepatic disease. 

Small aneurisms in various viscera are apt to have localized dilatations 
of the retinal arteries associated with them. They are almost unknown in 
the young, but are found connected with vascular changes in the special 
dyscrasise of the old, as renal disease, syphilis, etc. They are recognized 
either as large, oval pulsating tumors at or near the disk, or as minute pin's- 
head dilatations, generally situated in the bifurcations of the smaller arterial 
stems. Hockeu'^ instances an aneurism of the central artery of each retina. 

Intracranial aneurisms, which as a rule are basilar, very seldom, if ever, 
cause any visible dilatation of the retinal arteries. Leber says that in some 
cases of teleangiectasis of the conjunctiva and lids, the intraocular vessels 
are found in a similar condition. 

Sudden hemorrhage, especially if spontaneous and in subjects with 
greatly-impaired strength, may give rise to loss of sight, loith or without 
decided ophthcdmoscopic change. It may appear at any time of life, though 
most of the reported cases have been seen in adults. The blinding is 
double in about ninety per cent. U])on account of the many classes of 
subjects and the special dyscrasia and condition under observation, the 
ophthalmoscopic appearances described have been so varied that it would 
be impossible to formulate any strict typical picture. iS'euritis, retinal com- 
plication with hemorrhage, disk pallid, with diminished arteries and large 
veins, and total absence of symptoms, have all been noted by competent 
observers.^ If the disturbance has been profound, atrophic changes in the 
disks manifest themselves, and the eyes become permanently blind. 

The treatment consists in attention to the special disorder. 

In general ansemia retinal and optic nerve changes are almost protean. 
Gowers^ has seen neuritis in two chlorotic sisters sufferino^ from amenor- 
rhoea. Photo. VII., facing page 178, represents the appearance of the 
nerve-head in the first case, when the red corpuscles were sixty j^er cent, of 
normal, and the haemoglobin thirty per cent. After one recurrence " the 
disks were perfectly normal/' whilst the haemoglobin had risen to eighty 
per cent, and the corpuscles to ninety-six per cent. Bitsch* reports a 
similar condition in a girl of sixteen. Becker' has observed spontaneous 
arterial pulsation in similar cases. As a rule, the blood-currents appear 
impoverished, allowing in some instances the current of an underlying 
vessel to be plainly recognized through the contained material and walls 
of the upper one. Both sides of the vessel are flat and broadened. Hem- 
orrhages are rare. 

' A Treatise on Amaurosis, 1842, p. 36. 
' ^ See Norris's "Medical Ophthalmoscopy" in volume iv. of Pepper's System of 
Medicine. 

5 Medical Ophthalmoscopy, 1882, p. 328. 

* Klinische Monatsblatter, 1879, iv. 144. '" Ibid., 1880, i. 1. 



182 OPHTHALMOSCOPY: SYMPTOMATIC DISORDERS. 

The prognosis is favorable. 

The treatmeut consists in hygiene, nourishing and easily-digested foods, 
iron, etc. 

The condition in pernicious ansemia is totally different. The changes 
are more pronounced. The disk is pallid and its edges are ofttimes obscured. 
The arteries are pale, reduced in size, and frequently wavy. The veins are 
broad, flat, and tortuous, and contain pale blood. Striated hemorrhages 
appear along the course of the vessels. This is excellently shown by the 
accompanying reproductions of Jennings's diagrammatic sketches showing 
the progressive development of hemorrhages in the left retina of a case of 
an eighteen-year-old patient seen under the care of Dr. INIackenzie.^ The 
post-mortem examination left no doubt as to the genuineness of the diag- 
nosis, although " the question might be raised whether syphilis should be 
blamed for originating the blood-disease." 

The color of the entire fundus seems somewhat lighter than normal. 
Frequently, and more especially in the region of the nerve-entrance, there 
appear small whitish, irregular spots (lymphoid-cell agglomeration). Curious 
"irregularly round or ovoid hemorrhages with yellowish-white centres" 
have been seen by Norris.^ These centres, according to Manz,^ may either 
be composed of round, colorless cells enclosed in sacculations of the capil- 
laries, or be the empty dilatation of the vessel-terminals themselves. 
Quincke^ has seen both retinal oedema and stellate whitish opacities in the 
macular region. Marked optic neuritis has been found by ]\Iackenzie.^ 

There is no special treatment for the ocular changes, except rest of the 
eyes. Attention should be given to the general condition. 

In leucocythdemia the conditions noticed in the various forms of anaemia 
appear to be much aggravated, and in many instances may pass into actual 
inflammation of the retina. Not only has the choroid become lighter in 
tint and the retinal circulation more pallid in hue, giving the eye-ground an 
" orange-yellow" reflex,^ but hemorrhages are extremely apt to take place. 
Associated with these changes, isolated white and yellowish thickenings, 
probably due to aggregations of escaped leucocytes, with localized degenera- 
tion of tissue, may be frequently seen in the periphery of the fundus and 
around the yellow spot. According to Gowers, in some instances their 
areas are " edged by a halo of extravasation." OEdema of the retina, with 
white patches in the adventitia of the vessels, has also been noticed. This 
is beautifully shown in the accompanying reproductions from Becker's most 
instructive case^ in an adult female. The sketches were made nine weeks 

1 Transactions of the Ophthalmological Society of the United Kingdom, 1881, p. 51. 
^ Pepper's System of Medicine, vol. iv. 
3 Gowers, Centralbl. fur d. Med. Wiss., 1875, p. 675. 
* Deutsches Archiv fur Klin. Med., 1877, S. 1. 
6 The Lancet, December 7, 1887. 

6 See Liebreich, Deutsche Klinik, 1861, 50, and Becker, Archiv fiir Augenheilkunde 
und Ohrenheilkunde, 1869, 1, S. 951. 

' Archives of Ophthahnology and Otology, vol, i. No. 1, p. 341. 



DIAGRAMS. 



Fro. 1. 




Fig. 2. 




Fig. 3. 



Fig. 4. 





Fig. 5. 



Fig. 0. 





Progressive Development of Hemorrhages in Pernicious An^emia. (Mackenzie, Transactions 
of tlie Oplithalmologipal Society nf the Tnited Kingrtom, 1S81.) 



PHOTO. VIII. 




Retinal (Edema and Vasculak Opacities in Leucocyth^mia. (Becker, Archives of Ophthal- 
mology and Otology, vol. i., No. 1.) 

PHOTO. IX. 




Same Eye-Ground Nine Weeks later. 



OPHTHALMOSCOPY: SYMPTOMATIC DISORDERS. 183 

apart. Examination with the microscope in some of the cases has revealed 
a sclerosed and degenerate condition through the entire retinal structures. 
Through the kindness of Dr. John B. Shober and Mr. John Sailer (medical 
student) the writer has had opportunity to study the eye-grounds of a seven- 
year-old boy suffering from this form of disease. At the time of examina- 
tion the child had been under treatment for several months, but, in spite of 
this, both the arteries and the veins of the retina were somewhat tortuous 
and the venous currents appeared slightly pallid. 

HeinzeP has given a beautiful clinical picture of a case in a four-year- 
old child, in which, in addition to the other symptoms, there was intense 
swelling of the optic disks. 

The functional ocular trouble, of course, does not demand any special 
medication, rest of the organs being all that is necessary. The treatment 
must be directed towards the general condition. 

Purpura haemorrhagica and scurvy may ]3oth give rise to hemorrhages 
into the retina. Lawford^ gives an interesting case of double optic neuritis 
following purpura in a girl of twelve years. In the discussion, JSTet- 
tleship thinks that the symptoms pointed towards a localized papillitis 
rather than towards a descending neuritis, though it is remarkable that the 
disk-changes were not by any means so marked, even at the climax. Quite 
a number of cases have been reported. The prognosis for vision is depend- 
ent upon the amount and the situation of the extravasation. No special 
treatment is required, the intraocular condition being best combated by 
attention to the general condition. 

Lawford^ gives a most instructive section of a portion of choroid in- 
cluded in an area involved by a nsevus ; this occurred in an eight-year-old 
girl whose left eye was enucleated for glaucomatous symptoms. The left 
side of the child's face was occupied by a large dull-red capillary nsevus 
involving the eyelids ; the bulbar conjunctiva was not implicated. In front 
of the opposite ear a small patch existed. Under the microscope the blood- 
vessels of the choroid could be seen throughout the whole thickness of 
the tunic. 

Miller* gives a case of nsevus of the right temporal and orbital region 
with nsevus of the choroid associated with detachment of the retina in the 
right eye. Microscopically it appeared as a cavernous angioma. In this 
case, however, as Brailey remarks, it is curious that sequelse of inflamma- 
tion existed. A case of most probable venous angioma involving the skin 
of the right side of the face, the right sclerotic ("anterior ciliary"), and 
the retinal veins of the same side, occurring in a nine-year-old epileptic girl, 
is reported by Horrocks.^ In connection, it is of interest that left hemi- 

^ Archiv fiir Ophthalmologie, xxiv. 3, 241. 

2 Transactions of the Ophthalmological Society of the United Kingdom, 1882, p. 86. 

» Ibid , V. 136. 

* Loc. cit., iv. 168. 

^ Transactions of the Ophthalmological Society of the United Kingdom, iii. 106. 



184 OPHTHALMOSCOPY : SYMPTOMATIC DISOEDEES. 

plegia, more marked in the upper extremity, existed, and that the convulsive 
seizures caused clonic spasm of the left side of the trunk and its limbs. 

Local pulmonary disease cannot give any more than the ophthalmoscopic 
pictures indicative of disturbed vascularity, 

LESIONS DEPENDENT UPON DISOKDEKS OF THE NERVOUS SYSTEM. 

Brain and Envelopes. — In cerebral ansemia, according to Gowers/ per- 
manent amaurosis, probably due to an affection of the retina, may occur in 
cases which have had loss of sight during the attack. During the tonic 
portion of an attack of epilepsy, which presumes a probable anaemic condi- 
tion of cerebral substance, the fundus has been described as comparatively 
bloodless, the disk pallid, and the retinal vessels in a state of tonic spasm. 
Although this a jynori is most certainly true, yet the chances for observa- 
tion have been so few and the attendant difficulties so many that it will be 
necessary to observe a great number of cases before full credence can be 
placed in the few isolated and individual instances given. 

In opposition to the findings in a number of well-observed cases, it is 
most probable that there is an increase of retinal circulation and a suifusion 
of the disk during the active stage of cerebral hyperemia. Doubtful cases 
have been alluded to, but, as no distinctive changes of such a character have 
been accurately noted by competent observers, the subject must remain sub 
judice until a great number of similarly placed cases are associated in com- 
bined study. Extended and repeated ophthalmoscopic examinations of the 
fundus during ordinary syncopal attacks would go far towards a solution of 
this much-discussed problem. 

When cerebral hemorrhage takes place, which, of course, is very rare in 
children, occurring, for instance, as in Marshall's case, during an attack of 
pertussis, not only may there arise defects in the visual field, due to cortical 
pressure in the occipital region or pressure upon some portion of the intra- 
cranial extension of the optic nerve and tract with subsequent degenerative 
changes, but true retinal hemorrhages may exist. These conditions, how- 
ever, are relatively so infrequent that some authors give them but little 
place among the possible ocular symptoms in this disease. 

Based upon well-grounded clinical studies, we can confidently assert 
that no time of life, except the first few months of infancy and the very 
oldest age, is exempt from the formation of intracranial growtlis. The 
great prevalence of recognizable cases in childhood and adolescence (with 
those of early and full maturity) can be well understood when we consider 
that at these times mental activity, with its necessaiy accompaniment of 
marked and oftentimes intense cerebral action, is at its greatest, — a con- 
dition in which the slightest pathological formation in the cerebrum 
would make itself known by the many objective and subjective changes so 
common in these disorders. Although it is safe to assume that the intra- 

1 Medical Ophthalmoscopy, 1882, p. 123. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 185 

ocular disturbance is usually more pronounced and of longer duration in 
childhood and infancy than it is in similar disease during the later periods 
of life, yet it is so much more frequently overlooked, by reason of the youth 
of the subject and the greater difficulty of ordinary examination in such 
cases, that statistics fail to give any higher percentage of occurrence. If 
careful ocular examination should be made in every suspected instance of 
cerebral disorder, much more light would be thrown upon the true character 
and significance of the case, — additional symptoms which might prove of 
inestimable value in the accurate determination of such diseases. 

In childhood the tubercular, the gliomatous, and the sarcomatous types 
of intracranial growth are probably the most common ; the first especially 
permitting the choroid and the retina to share in the deposition. That this 
is true, and that some growths are more prone to express their presence 
peripherally in the eye-ground than others, is distinctly shown by Starr.^ 
He thinks, for instance, that as the gliomatous variety of tumor is very 
vascular and, as it were, erectile, variations in its disposition to erection 
mean corresponding increases in intracranial pressure, which in the majority 
of instances cause " sudden changes of intensity in the symptoms, accom- 
panied by visible changes of circulation in the retina ;" this intraocular 
condition being shown by such radical measures as " hot baths, cold douches 
to the spine, mustard baths to the feet, or free watery purgation." It is 
also quite probable that the cerebellar tumor is much more prevalent in 
childhood than in later life. 

Gowers's opinion,^ which is concurred in by Bramwell,^ that optic neu- 
ritis is present in at least eighty per cent, of all cases, is most probably 
nearly correct, in spite of the higher ratios of Annuske^ and Reich.^ 
Whilst the condition seems to be more prevalent when the neoplasm either 
involves the cerebral base or is embedded in the substance of the brain- 
mass itself, yet cerebellar growths seem to be remarkably prone to give the 
most intense forms of optic neuritis. Almost all observers agree that the 
presence and the degree of optic-nerve swelling and inflammation are in 
direct ratio with the rapidity of development and the quickness of growth 
of the tumor, and are not dependent upon the size of. the mass. 

In the great majority of cases the optic neuritis is double. Sometimes, 
however, during the course of the disease, the acute conditions in one eye 
may subside sufficiently for a careless or an incompetent observer to assert 
that there has never been any previous inflammation in the nerve, and that 
the intraocular expression of the disorder is limited to but one organ ; thus 
unfortunatelv invalidatino; much of the usefulness of the condition as a 
localizing symptom. As markedly illustrative of this, the writer has had 



' Medical News, January 12, 1889. 
2 Medical Ophthalmoscopy, 1882, p. 141. 
^ Intracranial Tumors, 1888, p. 6i. 
* Archiv fiir Ophthalmologie, xix. 3. 
5 Klinische Monatsblatter, 1874. 



186 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

the opportunity to watch the progress of a cerebral case for a long time, 
where a imiocular optic neuritis had been diagnosed, and yet where there 
were at times unequivocal symptoms of a low grade of neuro-retinitis in 
the fellow-eye, not only as shown by the ophthalmoscope, but also as evi- 
denced by slight though pronounced contraction of the visual fields, with 
decided diminution of central vision for both form and color. 

In those rare instances of true unilateral type, clinical investigation 
seems to point towards the opinions of Jackson,^ Broadbent,^ Pagenstecher,^ 
and others, who have shown that the inflammation of the nerve is on the 
side opposite to the brain-lesion. Bramwell ^ doubts this, and is of opinion 
that the present number of such cases is " too small to allow of any very 
definite generalization being made." In partial confirmation of the state- 
ment of the former observers, the writer has recently seen two cases of 
double optic neuritis — both in children — in which the lesser degree of 
neuro-retinitis was upon the same side as the intracranial growth. A third 
case, also in a child, just studied at present writing with Dr. Morris J. 
Lewis, in which the choking of the left optic nerve was one diopter higher 
than its fellow, showed a tumor of the pons which was more marked on the 
right side. In further support, the writer has just had another curious 
ante-mortem coincidence in an adult, where in a yet unpublished case, seen in 
association with Dr. Francis X. Dercum, all the general and special local- 
izing symptoms pointed towards a left-sided gross lesion. Here the right 
eye contained a large splotch-like hemorrhagic extravasation upon and 
around the optic disk, with an undue tortuosity of the retinal vessels, whilst 
the disks themselves appeared to be free from any coarse change. At the 
. autopsy, a sarcomatous growth was found deeply embedded in the left cere- 
brum, involving the pulvinar and contiguous portions of the internal capsule 
and the striated body. 

This can probably be best explained upon the supposition advanced by 
Broadbent in partial explanation of the monocular type of the optic neuritis, 
that the mechanical impediment to the passage of fluid into the intravagi- 
nal sheaths of the optic nerve by the growth is greater upon the affected 
side of the brain than it is upon the opposite. 

It must be distinctly understood, however, that this rule can only be 
true when the optic-nerve extravasation has been secondary, as it were, to 
the great increase of cerebral bulk. An illustration of the opposite condi- 
tion is to be found in Dr. James J. Putnam's^ most interesting exception, 
where a sarcomatous tumor, involving the posterior half of the right middle 
frontal convolution, gave a much greater optic neuritis upon the same side 
as the tumor-mass. Here it is most probable that the extravasation of the 

* Koyal London Ophthalmic Hospital Keports, vii. 573. 

^ Transactions of the Ophthalmological Society of the United Kingdom, p. 110. 
3 Eoyal London Ophthalmic Hospital Reports, vii. 130. 

* Intracranial Tumors, 1888, p. 36. 

» Boston Medical and Surgical Journal, April 10, 1890. 



OPHTHALMOSCOPY: SYMPTOMATIC DISORDERS. 187 

increased cerebral fluid into the optic-nerve sheaths was quite early in the 
later history of the case, thus allowing the greatly augmented after-pressure 
from the sudden and excessive exacerbation of the tumor-growth upon the 
right side, at the time when first seen at the hospital, to block the previous 
extravasation, and push it more forward into the interior of the right eye 
than into the left eye, and thus give the greater intraocular swelling upon 
the right side. This supposition is strengthened by the post-mortem exam- 
ination, at which " the surface of the right hemisphere was found pushed 
across the median line," " the base of the brain appeared normal, except 
that the optic tracts were excessively flattened by pressure," and " the right 
optic nerve was somewhat larger than the left, and reddish in color." 

From the time of Von Graefe's suggestion^ of increased intracranial 
pressure exerted upon the cavernous sinus, causing stasis in the ophthal- 
mic vein, — a theory which was soon cast aside on account of anatomical 
reasons, — to the latest modifications by Bramwell ^ of the combined notions 
of Leber ■'' and Deutschmann,^ of the presence of irritant micro-organisms 
in the cerebro-spinal fluid produced by the neoplasm, which, passing down 
the intravaginal space of the optic nerve, produce peripheral inflammation, 
many theories have been evolved for the causation of the condition. 
Though Bramwell's assertion (Joe. cit.) that " the pressure-irritation theory 
of Leber and Deutschmann is . . . the most likely explanation in the 
majority of cases," is most probably true in explanation of many instances, 
yet we must agree with the same author when he states, " I may at once say 
that, for my own part, I think it probable that the double optic-nerve 
neuritis of intracranial tumors is not always produced in the same manner." 
Besides, it must be distinctly understood that there are many similar in- 
stances of intracranial growths where, without any assignable cause of 
differentiation, optic neuritis is present in some and absent in others. 
Again, it must be remembered that there are examples on record of actual 
descending neuritis either in the contiguity of the nerve-tissue itself or in 
its trabeculse. In fact, the subject is still sub judice, and not until we shall 
be in possession of a long series of carefully-made clinical histories in asso- 
ciation with post-mortem examination of involved tissues by expert micro- 
scopists, combined with laboratory experimentation, will any legitimate 
generalization as to the causation of peripheral optic neuritis be possible. 

Xo sharp divisions can be given as to the age of the neuritis by the 
apparent grossness of objective alteration. Neither can any decided differ- 
ence between the ultimate result of two apparently diverse conditions be 
vouchsafed by the visible results alone. So much must be taken into con- 
sideration besides the ophthalmoscopic appearance, so many of the finer and 
almost imperceptible details of physical change seen must be carefully dif- 

' Archiv fiir Ophthalmologie, vii. 2, 88. 

2 Intracranial Tumors, 1888, p. 67. 

3 Klinische Monatsbliitter, 1868, S. 302. 
* Leber, Neuritis Optica, 1887. 



188 OPHTHALMOSCOPY: SYMPTOMATIC DISORDERS. 

ferentiated and understood by the ophthalmoscopist, and conditions vary 
so constantly in the same case, that numerous examples must be presented 
to the same trained eyes before adequate data of sufficient diagnostic impor- 
tance and prognostic moment can be given. 

Roughly, a type may be made from which all manner of departure must 
be expected. Thus, for example, in either a slight attack or in the incip- 
iency of a more pronounced one, the nerve-head will appear somewhat hazy ; 
the scleral ring is fainter and at times covered with a coarse thickening of 
the retinal fibres, — this latter condition being more pronounced to the inner, 
upper, and lower borders of the nerve. Ofttimes the retinal arteries will 
be a trifle too wavy, and possibly almost imperceptibly contracted near the 
disk, whilst the corresponding veins will be more than ordinarily tortuous, 
and will carry rather darker blood than usual. 

If the case be more pronounced, the disk will be actually swollen and 
pushed forward into the vitreous, the greatest amount of swelling being 
noticed in the upper, inner, and lower portions of the papilla ; the adjacent 
retinal substance will be prominent, and situated upon a higher level than 
that of the periphery of the membrrne; the scleral ring, with the adjoining 
pigment-massiugs so commonly seen to its inner and outer borders, will be 
absolutely lost to view beneath the swollen substance ; the retinal veins will 
be markedly tortuous, enlarged, and lost to view at many points, in and 
just beyond their passage into the nerve ; the corresponding arteries will 
appear greatly contracted whilst dipping in and out of the swollen tissues ; 
dark venous blood, and at times pallid arterial currents, are seen in the 
twisted and partially-blocked blood-channels ; fine striated hemorrhages, 
fan-like and flame-shaped, — especially at the bifurcation of the retinal 
vessels, — come and go, whilst small vessels which remain unapparent in 
health become plainly visible. This can be well seen in the accompany- 
ing phototypes, reproduced from Gowers's " Ophthalmoscopy" (2d edition, 
p. 359). 

When the active conditions have ceased, the involved tissues slowly 
pass into a state of quiescence. The nerve-swelling gradually decreases, 
the outer or temporal borders being those that are first seen. The retinal 
prominence lowers, carrying the retinal vessels to their proper levels. The 
vessels themselves become more nearly normal in appearance, and the blood 
extravasations slowly fade away. This can be plainly seen in the second 
picture (loc. cit). Should, however, more contraction of tissue take place, the 
nerve-material wnll still further squeeze the retinal circulation in its grasp; 
the retinal vessels, especially the arterie§, will diminish more markedly, the 
borders of the disk will become more or less pronounced, and the surface 
of the nerve will sink into irregular mouldings. The third sketch (foe. cit) 
well illustrates this. Should the case still progress, the changes of degen- 
eration will become more and more manifest to the ophthalmoscope, until 
at last, in not a few cases, so-called " total atrophy" will take place. 

As has been abundantly proved by most competent and painstaking 



PHOTO. X. 




Netjeo-Retinitis of Intracranial Tumor. (Gowers, Medical Ophthalmoscopy, 1882.) 



PHOTO. XI. 



PHOTO. XII. 





Partial Post-Neuritic Atrophy. (Gowers, Med- 
ical Ophthalmoscopy, 1882.) 



Regressive Neuro-Eetinitis of Intracra- 
nial Tumor. (Gowers, Medical Ophthalmos- 
copy, 1882.) 



ophthalmoscopy: symptomatic disorders. 189 

observers, no dependence can be placed upon the state of vision as an exact 
index of the amount of disturbance. Berry,^ Bramwell/ and others have 
all reported " good/' " perfect," and " normal" vision in cases where the 
ophthalmoscope has shown intense neuro-retinitis. Hughlings Jackson^ 
has seen instances where momentarv attacks of blindness have been as- 
serted, — these most probably the result of momentary increases of pressure. 
During the course of a neuritis a rapid permanent failure of sight in a few 
hours' time has even been noticed. INIackenzie ■* broadly asserts that he 
" would go so far as to say that in the practice of physicians who examine all 
their cases with the ophthalmoscope, whether the case was a cerebral one or 
otherwise, — whether there were or were not ocular symptoms, — iu at least 
one-half, if not more, of the cases in which optic neuritis was discovered, it 
would be found unassociated with any marked, and often without appre- 
ciable, defect of sight." 

As an example of one of the more constant objective symptoms of in- 
tracranial neoplasm, optic neuritis becomes one of the most valuable and 
important to the clinician. Usually unequally bilateral, it is almost certain 
to appear iu some stage of the disease. Taken alone, not much dependence 
can be placed upon it as a localizing symptom. Id conjunction with other 
ocular groupings and general motor and sensory disturbances, it becomes 
invaluable.^ Again, we must remember that, as Hughlings Jackson states,^ 
"optic neuritis points to the general nature of the local disease, not to 
its particular nature." It indicates, as he most pertinently says, the pres- 
ence of a " foreign body" alone. jNIoreover, we can understand that the 
exact position of the mass cannot be determined from this symptom alone, 
because, as we well know, a foreigu body, rapidly growing, will cause both 
direct and indirect pressure, with all their results, no matter in what intra- 
cranial point it may be situated. Certain it is that the nearer the mass is 
to the large fluid cavities aud their intercommunications, the more certainly 
are we to have peripheral expressions of mechanical interference, whilst 
the less removed the neoplasm is from the associated intracranial tissues of 
the second nerve and its internal prolongation, the more certainly must 
we expect to have results of pressure aud even destructive change : thus, 
roughly, cerebellar, deeply-seated cerebral and basilar growths seem the 
most prone to produce optic neuritis. 

The fact that increased intraocular pressure has time and again been 
sliOAvn not to be the sole cause of optic neuritis does not in any way mili- 

1 Diseases of the Eye, 1889, p. 301. 

2 Intracranial Tumors, 1888, p. 38. 

^ Transactions of the Ophthalmological Society of the United Kingdom, i. 70. 

*Ibid.,i. 95. 

* True as this may be in the main, it is equally certain that cases of double optic neu- 
ritis in association with other seemingly focal symptoms have been recorded where post- 
mortem examination has failed to reveal any gross intracranial lesion. Fagge furnishes us 
with a most instructive example. (See Bramwell, Intraocular Tumors, 1888, p 42.) 

** Transactions of the Ophthalmological Society of the United Kingdom, 1881, p. 82, 



190 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

tate against these views. It cannot be denied that in some cases of 
neoplastic formation Avith pronounced destructive changes there can be an 
actual descent of the inflammatory material along the tissues of the nerve 
itself. Travelling by means of the meninges along the arterioles, and at 
last reaching and inflaming the optic-nerve connective-tissue material itself, 
the intraocular expression of optic neuritis is obtained. Both Brailey and 
Edmunds have distinctly proved this.^ Still further, Edmunds ^ believes 
that it is a coexistent basilar meningitis from the brain-tumor which plays 
the role of causation of the double optic neuritis in such cases. 

Secondary optic atrophy is most probably produced by either direct or 
indirect pressure of the neoplastic formation upon some intracranial portion 
of the optic nerves themselves, or their prolongations backward. 

Prognosis. — If vision be momentarily impaired, as we sometimes find. 
especially in the so-called " choked disk" variety of optic neuritis, the 
ultimate visual result is always in direct relation with the amount of in- 
flammatory tissue-change or degeneration, which lessens physiological action 
to a degree in proportion with the amount of nerve-tissue left after the 
primary gain from the original amount of oedema has been efPected ; that 
is, there is a marked primary loss of physical action, the result of the 
initial changes, immediately followed by a gain of perception dependent 
upon the amount of restoration of physiological ability of the diseased 
nerve-tissue. Following this gain, there is a slowly-decreasing, vision, the 
result of post-ueuritic change, the amount of the final sight being dependent 
upon the degree of consecutive inflammation or degenerative change. Where 
the neuritis has taken place without previous choking, the vision gradually 
fades from the beginning without any intermediate gain, only to stop at a 
point which indicates cessation of the optic-nerve change. If the case be one 
of simple atrophy (either primary or secondary) ^ from the first, the gradual 
failure of vision is much more steady, and, as a rule, more pronounced. 

As treatment of the neoplasm by drugs is eminently unsatisfactory, 
and as the recent advances in cerebral localization with the brilliant results 
of antiseptic surgery render operative procedure for the removal of intra- 
cranial tumors so justifiable in many of the cases of accessible growths, 
careful study for such treatment should always be instituted. If syphilis 
be the suspected source of the growth, a proper course of alteratives with 
sarsaparilla, as Wood * suggests, should be tried. Should the mass be in- 
accessible, morphine injections, local applications of cold, as recommended 
by Bramwell,^ or free watery purgation, as spoken favorably of by the 

1 Transactions of the OjDhthalmological Society of the United Kingdom, 1881, p. 112 
et seq. 

2 Ibid. 

3 For definition of these terms see page 128 et seq. of vol. ii. of Gowers's Manual of 
Diseases of the Nervous System, 1888. 

* Pepper's System of Medicine, v. 117. 

° Edinburgh Medical Journal, 1879, p. 1073. 



OPHTHALMOSCOPY : SYMPTOMATIC DISOEDEES. 191 

same author/ may be used. Of course, local treatment of the optic 
neuritis itself — one of the eifects — is out of the question. 

As cerebral abscess is generally the sequel of supjsurative processes 
about the bones of the ear, it is usually situated, as shown by Barr,^ in the 
temporo-sphenoidal lobe of the same side. Case;^ of traumatic abscess, acute 
localized meningitis with pus-formation, aud metastatic abscesses have been 
reported by Harrison,^ Barker,* and Fraenkel.^ Extension from nasal and 
orbital disease lias also been seen. It is not uninteresting, therefore, in this 
connection, to note Keen's words :^ " Tlie presence or absence of choked 
disk does not seem to be pathognomonic, as it is sometimes present and 
sometimes absent. When present, even if bilateral, it is almost always 
more marked on the side of the lesion, though this is sometimes reversed." 
Thus associated with ear-disease it at times affords an important clue to 
the form of intracranial lesion. 

Though generally a disease of adolescence and early adult life, yet the 
proportion of occurrence in childhood is so high that its presence should be 
carefully considered in every case of neuro-retinitis where there is a proba- 
bility of intracranial mischief. It is certain that if the pus-formation be 
rapid and extensive, marked pressure will soon ensue, aud give rise to optic 
neuritis. As distinguished from that of tumor, the optic neuritis of abscess 
is usually not so marked, is more disposed to be unilateral, and is, as a rule, 
more decided in its onset. AVhen the abscess is situated posteriorly, the 
intraocular symptoms are generally wanting. As Keen says (supra), 
" Optic neuritis is not frequent in cerebellar abscess." Pfliiger,^ however, 
has seen one case of abscess of the left hemisphere of the cerebellum in 
Avhich double optic neuritis with both optic nerve and retinal hemorrhages 
existed. 

As vascular disease productive of thinning of vessel-walls is almost es- 
sentially a disease of adult life, intracranial aneurism as one of the results is 
almost unique in children. For this reason intraocular change expressive 
of the condition is comparatively unknown and seldom recorded. . " Prob- 
ably an ophthalmoscopic examination," as Gowers says,^ " would have 
revealed it in a larger proportion of cases." MicheP reports a double optic 
neuritis from pressure of a varix-like aneurism of the two internal carotids. 
Mitchell gives '" a most interesting case in an adult of an aneurism of an 
anomalous artery, causing antero-posterior division of the chiasm of the 

1 Edinburgh Medical Journal, 1877, p. 688. 

2 British Medical Journal, 1887, i. 723. 

3 Ibid., April 21, 1888. 

* Ibid., April 14, 1888. 

5 Deutsche Medicinische Wochenschrift, No. 18, 1887. 

* Eeference Hand-Book of the Medical Sciences, vol. iii. 
^ Archiv fur Ophthalmologic, 1878, ii. 171. 

8 A Manual of Diseases of the Nervous System, 1888, p. 497. 

* Archiv fiir Ophthalraologie, xxxiii. 2, S. 225. 

^^ Journal of Nervous and Mental Diseases, Januarv 



192 OPHTHAL.MOSCOPY : SYMPTOMATIC DISORDERS. 

optic nerves and producing bitemporal hemianopsia. The eye-grounds, 
which were studied by Dr. WiHiam Thomson, showed "no changes except 
at each papilla, where tlie vessels of the retina appeared perhaps somewhat 
attenuated, whilst the neuroglia, especially of the left eye, was pale, the 
porus opticus enlarged, and the appearances those of partial atrophy. 
There was no swelling of either papilla, nor any change in the retina that 
would indicate a previously ' choked disk.' " 

In either instance, whether the case be one of actual nerve-inflarama- 
tion, as in Michel's case, or of secondary nerve-changes from pressure, as 
in IMitchell's case, increased or continued growth of the aneurismal dila- 
tation must produce degenerative changes in the optic nerve. 

The prognosis as to sight is truly grave, and check of loss of visual 
power can only be expected from some radical surgical or manipulative 
procedure addressed to the main vessel or trunk itself. 

As the increase of the secretion of the choroid plexus in the lateral 
ventricles, etc., taking place in simple internal hydrocephalus, becomes very 
pronounced, there may be some dilatation in the calibre of the retinal 
veins; this, however, upon account of the comparative elasticity of the 
bony and cartilaginous structures and the yielding of the cranial sutures to 
internal pressure, is quite infrequent. In a few instances atrophic nerve- 
changes have taken place with and without signs of previous neuritis; the 
latter being most probably dependent upon pressure upon the internal pro- 
longations of the optic nerves themselves. In au acquired case in a three- 
and-a-half-year-old boy seen Avith Dr. W. W. Keen, the writer found a 
slight diminution of the retinal arteries with a corresponding enlargement 
of the retinal veins ; the nerve-substance being entirely too gray for the 
age of the patient. In this case there were no gross evidences of past optic 
neuritis. 

Pachymeningitis,- either external or internal, is so excessively rare in 
children that no unquestionable case of consequent optic-nerve inflamma- 
tion, as far as the writer's observation goes, is on record. This can be well 
understood when it is considered that small localized inflammations of the 
dura mater may be so trifling in their indirect results upon contiguous tissue, 
and exert such a minor degree of increased pressure, that neither marked 
inflammatory extension nor occlusion of outgoing lymph-channels by patho- 
genic material may ever take place during the course of the disease. If 
present, it is probable that in most instances it has been caused by direct 
implication of the optic nerve anterior to the chiasm, thus giving rise to 
the uniocular form of intraocular inflammation or degeneration. In associa- 
tion with Dr. Charles H. Burnett the writer has studied one such probable 
case in an adult.' 

In hsematoma of the dura mater, its occurrence is rather more often noted, 
not only upon account of the slightly greater frequency of the disease in 

' American Journal of the Medical Sciences, January, 1884. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 193 

childhood, but also because in these cases there is more changeability in the 
foreign and offending material. Optic neuritis may thus occur early, with 
the appearance of other acute symptoms, especially if the formation of the 
clot be rapid and extensive. 

Acute lejjto-meningitis of all forms, which is so common in children, is 
more prone to give ophthalmoscopic signs of its presence when the mem- 
brane is inflamed at the cerebral base. Its form of optic-nerve disturbance 
may be either some variety of descending neuritis, as regarded by Vou 
Graefe, or even perineuritis, as has been described by both Alt and Yon 
Ziemssen, though so-called " papillitis" has been seen and noted by compe- 
tent observers. 

As distinguished from the optic neuritis of brain-tumor, Bramwell ^ 
believes that " the papillitis associated with tumor is, as a rule, more in- 
tense than that due to meningitis ;" whilst Hughlings Jackson thinks that 
the swelling of the disk in tubercular meningitis is slight and not exten- 
sive, the disk appearing succulent. Gowers ^ says that the swollen nerve- 
head is paler than that which is usually found in similar conditions. In 
the few cases observed by the writer the optic disk appeared somewhat 
swollen, its edges were hazy, and the venous engorgement was slight ; the 
retinal hemorrhages ordinarily seen in optic neuritis being but once present. 
Occasionally, whitish areas with white points can be noticed in the retina. 

In the tubercular variety (see section on Tuberculosis) aggregations of 
tubers may be observed in the choroid. With the exception of the puru- 
lent type of meningeal inflammation, where intraocular evidences of thrombi 
and emboli may appear in addition to the neuritis, this form of the disease 
is most apt to give the most pronounced picture of nerve-head change ; this, 
no doubt, being in a measure due to intracranial aggregations of tubercles, 
which thus practically form tumors themselves. By careful and periodical 
search, Garlick^ ascertained its presence in twenty-one out of twenty-six 
cases. 

It is probable that were all cases of meningitis carefully examined 
ophthalmoscopically during the attack, many of the cases coming to the 
ophthalmologist later in life, with a history of past symptoms of cerebral 
disorder and consequent defect of sight, would show ophthalmoscopic 
signs of optic neuritis. In the chronic form of the disease the disks may 
become more and more atrophic after each subsequent slight exacerba- 
tion. In this case the value of the symptom is very great, as the disease 
may be so insidious, and its general symptoms so masked, that it is difficult 
to obtain any certainty as to the correct diagnosis. If the child be old 
enough, periodical examination of vision and the fundus oculi, with careful 
perimetric study, should be made, especially if any vague general symptoms 
indicative of the disorder appear from time to time. 

1 Intracranial Tumors, 1888, p. 45. 

2 Medical Ophthalmoscopy, 1882, p. 150. 

^ Medico-Chirurgical Transactions, 1879, p. 411. 
Vol. IV.— is 



194 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

In the syphilitic form, more especially in infauts, where the region of the 
posterior fossa is invaded and internal hydrocephalus from intraventricu- 
lar closure takes place, ophthalmoscopic signs of optic neuritis should be 
searched for in every instance. It is possible that Case II. of Hutchinson's 
clinical studies, " Amaurosis with White Atrophy of the Optic Nerves in 
Connection with Inherited Syphilis," ^ belongs to this category. 

In the epidemic, cerebrospinal variety of meningitis, optic neuritis appears 
late in the disease (about the fourth day), possibly partly owing to the com- 
parative invulnerability of the larger nerve-bundles to either peripheral 
neuritis^ or descending neuritis itself. After the primary attack of in- 
flammation, the nerve rapidly passes into a state of consecutive atrophy ; 
this is most probably due to the passage of a specific form of blood-poison 
acting so as to produce localized inflaramatory reaction, which is often dis- 
tinctly proved by the post-mortem appearances of purulent depositions in 
the uveal tract and the presence of thrombi and embolic infarcts in the veins 
of the retina. Both retinal and ciliary-body inflammation have been seen 
by Oeller.^ 

The grave form of the disease, where ophthalmoscopic changes are to be 
expected, is so i^pid in its termination, and the patient is usually so restless, 
that it is often difflcult, even when the pupils become dilated, to obtain any 
satisfactory view of the fundus oculi. In all such cases some mydriatic, 
such as homatropine or cocaine, should be employed. If the physician be 
at all expert, he will be able readily to examine the eye-ground whilst the 
patient is in a supine position.* 

If the media be sufficiently clear, the eye-ground generally gives all the 
conditions of the lodgement of emboli or thrombi to a greater or less degree. 

In spite of these conditions, cases have been reported where useful vision 
has remained, and where consecutive atrophic changes have stopped suffi- 
ciently early to prevent total annihilation of sight. 

In insolation, or thermic fever, while meningitis (even in the young) has 
been brought on by the direct action of heat caused by paralysis of either 
the heat-centres or the vaso-motor nerves through increased stimulus from 
exposure of the body to increased temperature,^ both optic neuritis and con- 
secutive atrophy may be seen. Hotz,^ who reports several such cases, goes 
further than this, in asserting that choroiditis of exudative type has been 
seen, its presence being due to extension of inflammatory material along the 
optic-nerve sheath. As Gowers,^ however, says, " the absence of choroiditis 



1 A Clinical Memoir on Certain Diseases of the Eye and Ear consequent on Inherited 
Syphilis, 1863, p. 164. 

2 See article by Mills, Medical News, March 3, 1888. 

3 Archiv fijr Augenkrankheiten, 1878, S. 357. 

* See Seguin upon this subject, Annual of the Universal Medical Sciences, 1889, ii. 59. 
= See Thermic Fever, or Sunstroke, by H. C. Wood, Jr., M.D., 1872, p. 102. 
6 American Journal of the Medical Sciences, July, 1879, p. 105. 
^ Medical Ophthalmoscopy, 1882, p. 161. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDEKS. 195 

in other cases of such extension renders the explanation difficult to accept." 
Fortunately, the disease is very rarely, if ever, seen in children. 

Insular sclerosis, an affection of every age of life, though more partic- 
ularly found among young adults, is a disease which is very apt to attack 
the second or optic nerve. Here we should expect to find degrees of visual 
loss of power in exact relationship with the number and the extent of the 
sclerotic patches in the sensory portions of the visual apparatus. Curiously, 
however, as Gowers ' says, " the nerve-fibres passing through are not de- 
stroyed, their axis cylinders persist, and retain impaired functional power, 
although their medullary sheath may disappear," If the patch be situated 
far back, impairment of sight, followed by secondary changes which may 
become visible ophthalmoscopically, can take place. Should the islet of 
sclerosis be near the ocular globe, inflammatory signs in the region of the 
disk may manifest themselves. Usually both nerves are affected, though, 
as a rule, they are disturbed unevenly. 

As nearly fifty per cent, of the cases of migraine, or hemicrania, are 
found during the period of adolescence, and as its subjective ocular symp- 
toms, which are so numerous, varied, and frequent, simulate those of serious 
organic disease, it has been thought well to give them in some detail. 
Temporary hemianopsia of a thin fog-like area which slowly sweeps across 
the lateral fields of vision, dense central spots which extend peripherally 
and lose their central density, and " large dim specks which either move lat- 
erally or diagonally,"^ generally either usher in the visual manifestations or 
mark the termination of a series of spectral appearances. At times there 
are vague impressions of moving water, or the appearance as if "the air 
itself were somehow visible, being composed of fine luminous grains which 
do not obstruct the vision" (Jog. ciL). If the hypersesthesise occur first, 
white or light zigzags, revolving concentric wheels, changing and blending 
colors, — in fact, as one patient says, " all manner of kaleidoscopic forms 
and colors that will not hold long enough to be examined," — are visible.^ 

In children these conditions may be associated with considerable rise of 
temperature, which, upon account of the general subjectiveness of the symp- 
toms, may ofttimes mislead one in the proper diagnosis of the case, and tend 
apparently to increase the gravity of the conditions. 



1 Medical Ophthalmoscopy, 1882, p. 168. 

^ Extract from the notes of a private patient. 

■^ This patient writes, " One curious thing, a sort of compensation for the discomfort of 
over-sensitiveness, is the vivid beauty of the impression made by colors which are rather 
tame to a health}^ eye. Sometimes, curling up in a certain big chair after dinner, and going 
off' in a five minutes' nap, my eyes on their first opening see in certain paintings on the 
wall some things which the artist probably aimed to say, but which do not always show ; 
something in the first glance out of the window : harmonies of tints, depths and perspec- 
tives in the lights and shadows, as if we had caught Nature unawares and off guard. Even 
the first glimpse under such conditions of the gilt lettering on some books on the shelves, 
some of them pretty shabby, too, aifects one with a positive thrill of pleasure at their 
heauty. ' ' 



196 OPHTHALMOSCOPY: SYMPTOMATIC DISORDERS. 

These, which are but a part of sensory disturbances, may at times be 
associated with motor derangements about the eye. 

One peculiarity seen in a case of the writer's was that the intensity of 
the coloration of the spectra decreased and their character changed as the 
attacks became less frequent and less intense : the colors became less vivid, 
and changed to those which are ordinarily seen with less peripheral or 
external stimuli ; ^ the forms became less pronounced, and the blind spots 
and blind areas less troublesome. 

Be the pathology what it may, though, most probably some change di- 
rectly or indirectly connected with cortex irritation and disturbance, it is 
possible that even here visible retinal changes may exist which are so slight, 
and so masked by ametropic and other local conditions, that no character- 
istic eye-ground expressive of the disturbance can be noted. As the case 
advances, however, and may pass through the stage of chorea (?) into epi- 
lepsy (?), the fundus- oculi changes may become more and more marked, 
until at last the peculiarities of retinal fibre thickening with slight peri- 
vasculitis, vessel tortuosity, and incipient red-gray degeneration are finally 
established as the visible results of a process which has been taking place 
within the intracranial substance, and which may be readily seen post 
mortem by careful examination with the microscope.^ 

Stanford Morton^ makes the curious observation of apparent obstruc- 
tion of retinal circulation in the right eye of a young woman of twenty 
years who was suffering from migraine. No evidence of cardiac lesion was 
obtainable, though the patient had had chorea for several years. No men- 
tion is made of the existence of rheumatism. 

Chorea. — In ordinary cases of chorea during childhood, fundus lesions 
have been generally regarded as negative : thus, Gowers * emphatically 
says, after describing three complicated cases where slight optic neuritis 
existed, " During the last twelve years I have examined with the ophthal- 
moscope a large number of cases of chorea, but have met with morbid 
changes in no other instance," ^ and De Schweinitz in a later communica- 



1 In this connection, though not exactly akin, it is of extreme interest to note the 
changes of color seen by Dr. S. Weir Mitchell's patient (quoted in Dr. Edward H. Clarke's 
unfinished essay, "Visions: A Study of False Sight (Pseudopia)," 1878, p. 246), who 
during a severe illness had a series of " visions." " Bright green" changed to " brown," 
and " vivid red" became " black," as her general symptoms subsided. 

2 Philadelphia Medical Times, February 5, 1887. 

* Ophthalmic Eeview, March, 1890. * Medical Ophthalmoscopy, 1882, p. 172. 

^ On page 558 of his " Manual of Diseases of the Nervous System," 1888, he uses these 
words : " In most cases of chorea the ophthalmoscopic appearances are those of health. In 
a few there is optic neuritis, usualh' slight in degree, just enough to be unequivocal. It 
passes away when the chorea is over. In only one case have I seen considerable neuritis, 
comparable to that seen in a case of tumor : the inflammation pa-ssed entirely away with 
the chorea. It is probable that the neuritis is related to the cause of the chorea rather than 
directly to the morbid process in the brain. Many of the patients had considerable hyper- 
metropia, and it is known that this condition disposes to slight neuritic changes in the 
disks, and may aid other influences in leading to the change." 



OPHTHALMOSCOPY: SYMPTOMATIC DISORDERS. 197 

tion ^ presents the following as one of his conclusions : " Embolism, atrophy 
of the disk, and optic neuritis may occur during or after attacks of chorea, 
but appearances in the fundus oculi characteristic of the disease have not 
been found." 

That these conclusions are true there can be no doubt, but curiously, 
in addition, in several cases where, through the kindness of Dr. Wharton 
Sinkler and others, the writer had opportunity afforded him to study the 
eye-grounds of such cases, the fundus in nearly every instance examined 
presented an appearance simulating, though to a minor degree, that seen 
in the eye-ground of children of the same age who were suffering from 
epileptic seizures, these fundus-changes being associated with a doubtful 
blood-pallor, and seemingly so pronounced and fixed, even after correction 
of refraction-error, as not to be wholly explained by any existent ame- 
tropia. Tliis coincidence, for at present it must be so considered (since 
insufficient material has as yet been seen from which to draw any positive 
conclusion), confirms the writer in the belief in the close relationship — if 
he may so term it — between migraine, chorea, epilepsy, and general paralysis 
of the insane (temporary and permanent cortex irritation, disintegration, 
and death). 

Another curious fact in these cases, not exactly appropriate here, but 
which the writer intends to explain more fully in a more suitable place, 
is a decided clonicism of the ciliary muscle in a few cases, giving rise to 
apparent momentary increases of refraction.^ 

The two cases of embolus of the central artery of the retina seen by 
Swanzy ^ and Foerster (quoted by Gowers *) can be possibly explained upon 
the supposition of cardiac disease, which has been found to be so prevalent 
in such cases. Sym's case ^ probably belongs in this category. 

For the relief of any eye-strain we should see that every ametropic child 
has its refraction-error thoroughly corrected by the use of a mydriatic, 
taking care to know that both the lenses and their mountings are properly 
and carefully readjusted every few months. The Weir Mitchell plan of 
rest-cure may be made of great use in these cases, together with short 
stances of judicious movements " slowly done loith force and completely 
■finished" as suggested by Seguin.^ 

In spite of Gowers's belief^ that " the appearance of the fundus oculi 
between the paroxysms is, as a rule, normal" ^ in epilepsy, yet it is absolutely 



1 New York Medical Journal, June 23, 1888. 

^ Momentary lessening of hypermetropia, reversal into myopia, and increases of 
myopia, through all grades and amounts of astigmatism. 
'^ Royal London Ophthalmic Hospital Eeports, viii. 181. 
* Medical Ophthalmoscopy, 1882, p. 171. 

5 Edinburgh Medical Journal, March, 1888. 

6 New York Medical Journal, April 5, 1890. 
T Medical Ophthalmoscopy, 1882, p. 172. 

8 Further on in the text, the author modifies this statement by the following words : 
" The only deviation from the normal state of the fundus which has seemed to me frequent 



198 ophthal:moscopy : symptomatic disorders. 

certain that if a series of careful observations be made in any variety of 
this disease, a type of eye-ground will soon manifest itself to the observer, 
this being the more pronounced in those cases where the seizui'es have taken 
place over a long period. ISTot only has the peculiar condition been found 
among adults, but it is plainly manifest in younger subjects.^ 

The nerve-head ajjpears dull red-gray, whilst its edges are hazy and 
hidden above and below by a fine (sometimes coarse) retinal striation which 
extends far out into the periphery of the fundus. Both the arteries and the 
veins of the retina are tortuous and a trifle large in size, whilst the vessel- 
walls appear thickened. The choroid itself seems somewhat disturbed. 
This picture is so constant in varying degrees, and is seemingly so uni- 
formly in direct relation with the gravity and the number of the paroxysms, 
that it can be only considered as the visible ophthalmoscopic result of a 
similar condition in the related cerebral cortex, which may be seen post 
mortem in these subjects by careful study with the microscope.^ Knies'' 
has since found identical changes in the retina and optic nerve. As most 
of these cases were idiopathic in type where post-mortem examination failed 
to reveal any gross macroscopic lesion of either the intracranial or the 
ocular contents, but where the microscope showed signs of cortex irritation 
and inflammation, with similar changes in the retina, it must be conceded 
that the slight and easily-overlooked intraocular expressions noted bore no 
relation whatever to the sequels of old syphilis, such as choroiditis, chorio- 
retinitis, etc., or to the results of coarse organic lesion of the brain, such as 
neuro-retinitis, retinal hemorrhage, etc. 

Moreover, jSTorris * says, " In several of the chronic cases which the 
writer has had an opportunity of examining, there has been a low grade of 
atrophy of the disks, with concentric limitation of the field of vision." In 
confirmation of this latter statement, the present writer, in an analysis of 
the ocular symptoms obtainable in epilepsy in the male adult,^ has found the 
visual fields for form and color reduced to from one-third to one-twentieth 
of normal areas. Both Allbutt and Bouchut hold that the disks appear 
congested during the " iuterparoxysmal state." Kostl and Memetschek\s 
assertion ^ of the comparative frequency of spontaneous venous pulsation 

is an unusual equality in size of the retinal arteries and veins. The latter are not, as a 
rule, larger than normal, and the arteries appear as if large from a lax state of wall." 

1 Through the kindness of Drs. Isaac N. Kerlin and A. W. Wilmarth, the present 
writer has been enabled for the past two years to engage in studies upon this and kindred 
subjects at the Pennsylvania Institution for Feeble-Minded Children at Elwyn, Pennsyl- 
vania. As soon as the records are sufficiently complete for proper generalization they will 
be published. 

2 See Second Annual Report of the Pathological Department of the State Hospital for 
the Insane for the South-eastern District of Pennsylvania, by Di-s. Francis X. Dercum and 
Ida V. Eeel. Published in Seventh Annual Eeport of the Hospital, 1886. 

3 La Semaine Medicale, June 13, 1888. 
^ Pepper's System of Medicine, vol. iv. 

5 Philadelphia Medical Times, February 5, 1887. 

6 Prager Vierteljahrschrift, SS. 106 u. 107. 



OPHTHAJ.MOSCOPY : SYMPTOMATIC DISORDERS. 199 

has not been substantiated by so careful an observer as Gowers ; ^ it is like- 
wise certain that in a large number of notings of cases which have been 
zealously and painstakingly studied by the present writer there cannot be 
found a single record of such a symptom. 

During the convulsive seizure, ophthalmoscopic examination is so diffi- 
cult that diverse opinions have been sedulously contended for by various 
observers. Pallor has been the most frequent, as noted by Hughlings 
Jackson,^ Schreiber,^ and Arlidge/ whilst both congestion and pallor have 
been recognized by Allbutt.^ In the tonic stage of the paroxysm Gowers * 
has noticed increase in both size and darkness of the retinal veins. In one 
case seen by the present writer, where a convulsive seizure ensued during 
the time that the eye-ground of an epileptic patient was being studied by 
the direct method, an imperfect view of the fundus oculi was obtained 
during the cyanotic stage, which not only revealed a questionable increase 
in size of the retinal vessels, but also gave a doubtful enlargement of 
the size of the entire details of the fundus ; this, if correct, may be at- 
tributed to a possible tonic contraction of the ciliary muscle during the 
general tonic spasm, Avhich produced a temporary increase in the convexity 
of the crystalline lens, with apparent enlargement of the ophthalmoscopic 
image, — a solution of a problem akin in a measure, though probably more 
plausible, to that suggested by Knies'^ to explain the apparent change in the 
size of the retinal vessels.* Finkelstein,^ who has studied the fields of 
vision immediately following epileptic seizures, has found some very curious 
and interesting temporary changes in order, size, and perversion, and believes 
that these peculiarities, in association with some similar conditions of ordi- 
nary color-perception, may prove of value in the differential diagnosis of 
true and simulated epilepsy. 

The eye-grounds in idiocy, which are now being studied by the writer, 
have in a considerable number of instances given characteristic congenital 
anomalies with pictures of products of inflammatory change. 

The mental grade of imbecility — i.e., the ability of the subject to make 
continued use of the eyes for prolonged near work — seems to bear greatly 
upon the condition or appearance of the fundus oculi. In the lower grades, 
where mentality is of such a character that the eyes are seldom, if ever, 
used, the fundus iu most instances fails to present those changes, such as 
" dirty red-gray appearance of the optic disk ; irregularity of physiological 
excavation ; non-visibility of the superior and inferior portions of the 

1 Medical Ophthalmoscopy, 1882, p. 173. 

2 Lancet, February 17, 1874. 

^ Ueber Voranderuiigen des Augenhintergrundes, 1878. 

* West Riding Asylum Reports, i. 

^ On the Use of the Ophthalmoscope, 1871. 

6 Medical Ophthalmoscopy, 1882, p. 173. 

1 Sitzungsbericht der Heidelberg. Ophth. Gesellschaft, 1877. 

^ See Gowei-s's Medical Ophthalmoscopy, p. 174, ed. of 1882. 

s Inaugural Dissertation, 1887. 



200 OPHTHALMOSCOPY : SYMPTOMATIC DISORDEES. 

scleral ring ; absorbing conuses in all of their varieties ; increase in density 
and thickening of the retinal fibres ; opacities of the vascular lymph- 
sheaths ; disturbed states of the choroid ; and gross errors in astigmatism, 
with changes in indices of refraction," ^ which are so ordinarily found in the 
abused eye of the mentally healthy at the same age.^ 

The case is far different when the little patient has been placed in the 
highest grade of school training. Here not only do we see the abused 
tissues of the overused eye of childhood, but we find that the changes in 
refraction-error, with all the consequent fundus peculiarities, are much more 
prevalent and jjronounced than among the mentally healthy placed under 
the same condition of school hygiene. 

Spinal Cord and Coverings. — Contrary to common belief, acute inflam- 
mation of the spinal cord proper {myelitis) has most certainly at times eye- 
ground symptoms associated with it. Noyes ^ gives a remarkable instance 
in a young man. Steffen,* Erb,^ Chisolm, and Seguin have all seen cases. 
The intraocular symptoms are described as low-grade optic neuritis, asso- 
ciated with all degrees of lowering of central vision and decided though 
changeable diminution in the visual fields. 

Sharkey and Lawford ® add a case of acute optic neuritis with acute in- 
flammation of the spinal cord. Their case (in a seventeen -year-old girl), 
which happily embraced both an extended clinical history and a most care- 
ful study with the microscope of the involved tissues, showed intense in- 
flammation of the optic disks, nerves, and chiasma, with a less involvement 
of the tracts, whilst the adjacent meninges gave slight evidences of inflam- 
matory change. 

According to some observers, spinal concussion has been productive 
of failure of vision. Allbutt,^ who believes in an association between the 
two conditions, attributes the fundus-lesious to the effects of meningeal 
disturbance. Noyes^ relates a case in an adult, where, after the receipt 
of a sudden and severe blow upon the lower end of the spine causing 
intense pain at the base of the skull and along the spine, there were de- 
fective vision and contracted fields. Ophthalmoscopically, " there was ex- 
treme hyperemia of the optic disk both in the large and small vessels." 
He believes that a paralysis of the fibres of the sympathetic might well be 
assumed as the cause of the vascular dilatation. Erichsen ^ asserts that in 
the vast majority of cases unattended by fracture or dislocation there was 
distinct evidence of visual impairment. Examination of his cases shows 

1 See Transactions of the American Ophthalmological Society, 1887. 

^ This is true even in the adult imbecile of the same grade. 

s Archives of Ophthalmology, 1880, ii. 199. 

* Sitzungshericht der Heidelberg. Ophthalmologischer Gesellschaft, 1879. 

^ Archiv fiir Psychiatrie, x. 146. 

^ Transactions of the Ophthalmological Society of the United Kingdom, i. 240. 

^ The Ophthalmoscope in Diseases of the Nervous System and of the Kidneys, 1871. 

8 A Text-Book on Diseases of the Eye, 1890, p. 631. 

9 On Eailway and Other Injuries of the Nervous System, 1875. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 201 

that vision was impaired in about one-seventh of the total number. Neces- 
sarily this proportion must be accepted cum grano sails, upon account of the 
omission of careful ophthalmic examination in the greater number of his 
recorded and quoted instances. 

The symptoms generally complained of are a species of hemeralopia, 
muscular asthenopia and insufficiency, and double sight, followed by muscse 
volitantes and colored vision. Conjunctival congestion has also been noted. 
As all these conditions are subjective, care must be taken to ascertain that 
there is no malingering, especially in cases of young hysterical persons. 
Careful tests for all manner of deception, with close examination and con- 
sideration of every related ophthalmic symptom, should be made before any 
opinion is given as to the relation of doubtful cause and apparent effect. 
(See section on malingering.) Thorburn,^ after a comparison of some fresh 
investigations with the past conclusions of others, says, " From the above 
summary we are led to the conclusion that the occurrence of optic neuritis 
is extremely rare in the cases formerly described as concussion of the spine, 
and that even when present there is no indication Avhatever that it bears 
any relationship to a lesion of the spinal cord." He has no faith ^ in the 
association of the intraocular disease with a doubtful spinal traumatism 
in Thorowgood's observation,^ where " choked disks" appeared in a young 
healthy girl twelve years of age, one month after a blow received upon the 
lower part of the back.* 

Philip C. Knapp^ has written a most careful paper upon the whole 
subject. 

The pathology and etiology of Friedreich's ataxia are still obscure. 
According to Friedreich,^ Mdbius,'^ Grasset,^ and others, it is merely a species 
of tabes dorsalis caused by primary degeneration of the posterior columns 
of the cord with secondary meningitis. Bourneville ^ and Ross,^'^' however, 
associate it with insular sclerosis, whilst Gowers " finds a correlation between 
it and ataxic paraplegia. 

In this probably the only ordinary form of tabes dorsalis seen in child- 
hood,^^ intraocular signs of sensory disturbance have, according to the most 

1 A Contribution to the Surgery of the Spinal Cord, 1889, p. 182. 

2 Op. cit, p. 178. 

^ Transactions of the Clinical Society of London, 1875, p. 80. 

* Could disturbed menstrual function have been a factor in the production of the optic- 
nerve change ? 

5 Boston Medical and Surgical Journal, November, 1888. 
^ Virchow's Archiv, 1888, xxvi. 
^ Schmidt's Jahrbiicher, 1884. 

* Traite pratique des Maladies du Systeme nerveux. 1881. 

^ ISTouvelle Etude sur quelques Points de la Sclerose en Plaques disseminees, 1869. 

'" Hand-Book of the Diseases of the Nervous System, 1885, p. 527. 

" A Manual of Diseases of the Nervous System, 1886. 

^'' As an exception to this rule, see case at ten years of age by Eulenberg (Boss, Diseases 
of the Nervous System, p. 213). Another, from Erb's practice (Ziemssen's Cyclopa?dia, xiii. 
624), is quoted by Sinkler (Medical News, July 4, 1885). 



202 ophthal:moscopy : SY:\rPTo:vrATic disordees. 

careful analyses of recorded cases by Griffith/ been very rarely seen, if at 
all. Out of one hundred and forty-three cases, he found ophthalmoscopic 
examination noted in thirty-eight instances, and in none of these were there 
any changes of importance except in Power's cases,^ in which the disks 
were rather white, and in one of Seguin's,^ in which there was " partial 
atrophy of both optic nerves." Continuing, he says, "The condition of 
the color-fields might prove of interest in showing the possible relation of 
the disease to locomotor ataxia. Very little has been done in this direc- 
tion, though Oliver made a careful examination of one of Sinkler's cases * 
and found narrowed fields, leading him to believe that there existed ocular 
changes allied to those of tabes." In this instance, which was most 
carefully studied, the writer found incipient optic-nerve degeneration, as 
evidenced by the ophthalmoscope and shown by slight subnormal color- 
perception for green, with marked contraction of the visual fields, more 
pronounced on the left side. These sensory changes in association with a 
pronounced horizontal nystagmus induced him to conclude that he was 
dealing with ocular conditions which were related to some peculiar form of 
locomotor ataxia. 

Through the kindness of Dr. J. P. Crozer Griffith, and with the assist- 
ance of Dr. H. W. Cattell, the writer has been able to study the ocular 
conditions of two of the personal cases mentioned in Dr. Griffith's "Contri- 
bution to the Study of Friedreich's Ataxia" {supra). In the case S. J. he 
was enabled to verify Dr. Turnbull's original statement, " The result of the 
ophthalmoscopic examination of the eye-ground . . . was entirely negative." 
In the third case (Annie C), where Dr. Turnbull two years previously had 
reported " ischsemia of the retina and venous pulsation in both eyes, but no 
other alteration of the eye-grounds," there was decidedly less capillarity to 
the temporal portions of the optic-nerve substance, though the disks ap- 
peared otherwise healthy ; this loss of capillarity being more pronounced in 
the left eye. Vision with the right eye was reduced to two-thirds of nor- 
mal, whilst that with the left eye was but one-third of normal. Fields of 
vision for form were contracted to one-fifth (right) and one-sixth (left) re- 
spectively ; there being a series of indentations in the periphery of the color 
areas, especially down and in. Tension was normal in each eye. Media 
were clear. 

It would be both interesting and instructive to have a careful ophthal- 
moscopic record with a painstaking perimetric examination made in every 
case falling under observation, so that if the optic-nerve changes be constant 
they may be included in the symptomatology of the disease. 



^ Transactions of the College of Physicians of Philadelphia, Fehruary 1, 1888. 

2 St. Bartholomew's Hospital Keports, 1882, p. 305. 

3 New York Medical Kecord, March 13, 1885, and British Medical and Surgical Jour- 
nal, October 15, 1885. 

* Philadelphia Medical News, .July 4, 1885. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 203 

In latei^al sclerosis ophthalmoscopic changes are said by Gowers ^ to be 
very rare. He nevertheless notes an instance of repeated transient attacks 
of amblyopia followed by optic-nerve atrophy ; the symptoms appearing in 
an adult male whom he supposed to be suffering from the disease. In a 
nineteen-year-old girl seen by the writer through the courtesy of Dr. G. Bet- 
ton Massey, repeated ophthalmoscopic examination extending over several 
years showed that the right optic nerve continued slightly the healthier in 
appearance^ and gave somewhat better visual results through the entire 
period ; though the visual acuity, color-perception, and visual fields of the 
left eye were always but slightly below normal. 

Unclassified Neuroses. — As hereditary optic-nerve atropky is significant 
of a form of lesion which most certainly appears to be associated with 
heredity, there can be no doubt of the correctness of the use of the term 
in this connection. As early as 1817 it was recognized by Beer,^ who gave 
a detailed account of three generations in whom the females became blind 
about the time of menopause, and where, curiously, the" brunettes of the 
family were those affected. Travers ^ instances another series in two gener- 
ations, whilst Sedgwick'* gives a most peculiar family grouping, where 
the blindness appeared at sixty in the father and where the sons became 
successively earlier and earlier affected. Habershon ^ gives an exhaustive 
account of the literature and a resume of a large number of personal in- 
stances. Four generations of the disease are noted by Haswell.^ AVardrop^ 
says that he has " known several instances of this kind." Weller ® cites an 
interesting example where an autopsy showed that the " medullary mat- 
ter of [the optic] nerves had been completely removed. '^ Thomseu's ^ case, 
which developed melancholia later in life, is interesting by reason of a sup- 
posed seventeen years' remission. Jacobson^° attempts to explain the condi- 
tion in a child born of a seemingly normal-eyed mother, as dependent upon 
an intra-uteriue pathological process that had disturbed the already fin- 
ished optic nerve. Leber {loc. ciL), who has given us a systematic study of 
the whole question, believes that a peculiar neuropathic tendency, such as 
neuralgias, dizziness, ausesthesias, and even epileptiform seizures, exists in 
all these cases. He thinks that it generally manifests itself a short time 
after adolescence, though it has been observed quite early in life. Con- 
sanguinity does not seem necessary, and in fact it is not usually found. 



1 Medical Ophthalmoscopy, 1882, p. 168. 

2 Lehre von den Augenkrankheiten, etc., 1817, ii. 442. 

3 See Leber's paper, Archiv fiir Ophthalmologie, xvii. 2, S. 249. 

* 3Iedical Times and Gazette, March 22, 1862. 

5 Transactions of the Ophthalmol(jgical Society of the United Kingdom, viii. 190. 

* British Medical Journal, December 3, 1887. 

^ Essays on the Morbid Anatomy of the Human Eye, 1818, ii. 189. 

8 Manual of the Diseases of the Human Eye, 1821, ii. 79. 

9 Mimchener Medicinische Wochenschrift, March 27, 1888. 

w Centralblatt fur praktische Augenheilkunde, December, 1887. 



204 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

Norris ^ has had the rare opportunity of making a most careful ophthalmo- 
scopic study of seven cases (four boys and three girls), the children of 
an unaffected mother who was the sister of two affected brothers and one 
unaffected sister, the grandmother of this generation being affected. His 
youngest case appeared in a seven-year-old boy ; the tendency, as shown 
in Sedgwick's series, being that the younger children should be attacked 
the earliest. 

Most writers look upon the disease as one manifesting itself about the 
time of puberty, whilst others have failed to recognize it until later in life. 
Littell ^ notes an instance where " four or iive children in one family were 
born blind, the parents themselves enjoying perfect vision." 

The subjective symptoms are quite characteristic : more or less frontal 
headache ; dizziness ; attacks of " fogging of vision" during perspiration, 
without watering of the eyes; various-colored phosphenes (red and blue 
stars, etc.) appearing in the centre of the visual field ; gradual diminution 
of power of central vision ; ocular pain upon exposure to light ; visual fields 
markedly and irregularly contracted, with varying sizes and densities of 
central scotomata ; gradually decreasing normal color-perception, passing 
through the various colors, green, red, blue, and yellow, until at last nothing 
but equal intensities of color are laid side by side, without reference to tiut.^ 

Ophthalmoscopically, the changes in the optic nerve which are so well 
described by Norris (supra) may be summed up as follows : " 1. The stage 
of cloudy and oedematous swelling," where the disk is still capillary and 
hazy, its normal outlines partly or entirely hidden, and its substance slightly 
swollen. " 2. That of lymph reflexes, where the haze and swelling have 
lessened, and the disk has become slightly grayer." In this stage there 
appear numerous silvery and yellowish-white reflexes situated in front of 
the retinal vessels, mostly marked in the macular region, which, according 
to the author, are " probably partly due to capillary vessels of the retina 
which have become visible by the thickening and clouding of their walls, 
partly to the enlargement of the lymph-channels of the retinal tissue." 
" 3. That of general death of the nerve-tissue ;" here the reflexes lessen, 
the retinal vessels dwindle, and the tissue of the disk gradually becomes 
atrophic and assumes a greenish tint. 

It will thus be seen that its early recognition in children depends upon 
carefulness of clinical study and the understanding of slight but significant 
changes in the fundus. From what has been said, it is fair to assume that 
the disease is as truly progressive in its early stages as later on, when even 
almost' incompetent study cannot fail to expose its existence. The child of 
seven or eight years is as truly a sufferei', and in need of as much hygiene 



^ Transactions of the American Ophthalmological Society, v. 662. 

2 Manual of the Diseases of the Eye, 1846, p. 215. 

3 This series of color-change and loss, which the writer has been so fortunate as to 
study in Dr. Norris's grouping of cases, is exceedingly interesting, and is of value, in the 
pathological sense at least, in the study of the evolution of the color-sense. 



OPHTHALMOSCOPY : SYMPTOMATIC DISOEDERS. 205 

and therapy to endeavor to prolong the hfe of one of its most valuable 
organs, as the man of fifty years. The child of three or five years belong- 
ing to such a family, even though not presenting any macroscopic signs of 
disease to our ordinary instruments of precision, is even more to be protected 
and cared for, in the hope of averting such a calamity, than the one of 
older years. The conditions seen in youth are just as indicative of this 
terrible heirloom as are the grosser lesions and their more dire consequences 
when found in the related adult. Early youth and infancy are the only 
times in the individual's life when we may hope by most careful and even 
extraordinary regimen and studied prophylaxis to mitigate or suppress 
the manifestation of this dread disorder. As each year in life is passed, the 
greater the changes become, and the less likelihood is there for repair or 
betterment of condition. What its true pathology may be — axial neuritis 
or vascular disturbance — autopsy will alone show. So far we are in the 
dark. Many theories might be proposed, each holding a grain of truth, but 
the knife and the microscope can alone give the answer. 

Strychnine, as advocated by Mooren, Leber, and Norris, probably acts, 
as the last-named author states,^ by increasing arterial pressure, so as to 
give greater flow of nutriment through shrivelled optic-nerve capillaries. 

Whether it be true or not that exopMliahnic goitre has its pathogenesis 
in the cerebral mass,^ yet according to Gowers ^ the fundus in this disease 
is, with the exception of arterial pulsation and oedema of the disk, usually 
quite normal ; elsewhere * he says that " the retinal arteries participate in 
the general arterial dilatation which occurs so uniformly in the disease 
and is ascribed to a paralysis of the sympathetic vaso-motor fibres." Berry ^ 
asserts that in his experience " pulsation, at any rate, is much less frequent 
than is assumed by some writers on this subject, and than might perhaps 
be expected from the evident want of tone in the arteries of the head and 
the excited state of the heart's action." Norris ^ says that " ophthalmo- 
scopic examination usually shows a slight thickening of the fibre-layer of 
the retina in and around the disk, with dilatation and tortuosity of the 
veins, a state of affairs which may often be fairly attributed to a venous 
stasis caused by the swelling tissues." He further remarks, " In addition 
to these symptoms, there is sometimes, as Becker has pointed out, a dila- 
tation of the arteries, which may almost equal the veins in calibre. At 
times there is an arterial pulse." This arterial pulsation, which has been 
seen and described by Becker,^ is both spontaneous and variable. 

In an analysis of thirty-two cases of Graves's disease occurring at the 

1 Transactions of the American Ophthalmological Society, 1882. 

2 See article by Leplaine, Gazette des Hopitaux, 1889, No. 5. 

3 Manual of Diseases of the Nervous System, 1888, p. 811. 
* Medical Ophthalmoscopy, 1882, p. 170. 

5 Diseases of the Eye, 1889, p. 386. 

6 Pepper's System of Medicine, vol. iv. 

^ Klinische Monatsblatter, January, 1880. 



206 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

Manchester Roya] Eye Hospital, Hill Griffith ^ found but three cases under 
twenty years,^ in one of which, although the eye-grounds -were designated 
as normal, with no arterial pulsation, yet the disks were hypersemic. Spon- 
taneous arterial pulsation was not found in a single case. West ^ denies 
any retinal changes "■ except some fulness of the veins in a few." Lang 
and Pringle * give a case in a fourteen-year-old boy whose fundus was said 
to be normal. 

There can be no doubt that in the majority of cases, when carefully 
studied with the upright image, there can be detected a true venous stasis, 
associated with pronounced retinal striation. In some instances, where 
there is but little associated intraocular change, this venous tortuosity and 
dilatation may be fairly attributed to general vascular disturbance, — thus 
forming an intraocular guide, as it were, to the condition of the patient. 
In the notes of the few examples that the writer has seen, there is no record 
of spontaneous arterial pulse or enlargement of the arteries. These fuudus- 
changes, of course, need no special treatment, as they merely represent some 
of the minor and least important symptoms in the disease. In fact, they 
form, as it were, a part of the natural history of the disorder. 

Numerous cases of probable reflex sensory disturbance of the second 
nerve or its internal prolongation from irritation or injury of large adjacent 
nerve-trunks, such as the trigeminus, have been recorded. The Avritings of 
the older ophthalmologists, such as Beer,^ Wardrop,^ and Middlemore,^ 
abound in curious instances. The last-named author reports a remarkable 
though questionable case.^ De Wecker,^ Hutchinson,^'' Widmark,^^ Gale- 
zowski,^^ and others relate instances, both in adults and among children, 
where amblyopia is supposed to have arisen from dental irritation. 

All such cases should be most carefully studied before a diagnosis is 
vouchsafed. Accurate ophthalmoscopic records, with repeated examination 
of the visual fields and color and form perception, should be made in every 
suspected instance, so that more accurate data as to the ophthalmic group- 
ings may be obtained. These studies, in association with careful explora- 
tion of the general system, may j)rove of the utmost value in determining 
a question which must remain undecided until all doubtful points of differ- 
ential diagnosis have been definitely settled. 

1 Transactions of the-Ophthalmological Society of the United Kingdom, 1886, p. 60. 
^ Two cases only can be found in the table. 
3 Op. cit., p. 76. * Op. cit., p. 108. 

^ Lehre von den Augenkrankheiten, etc., 1817, i. 195. 
•> Essays on the Morbid Anatomy of the Human Eye, 1818, ii. 179. 
^ Quoted by Lawrence in his Treatise on the Diseases of the Eye, American edition by 
Isaac Hays, 1843, p. 109. 

® Treatise on Diseases of the Eye, ii. 364. 

8 Annales d'Oculistique, 1866. 

^° Royal London Ophthalmic Hospital Reports, iv. 881. 

" Annales d'Oculistique, September-October, 1888. 

1^ Revue Generale d'Ophtalmologie, October, 1888. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 207 

LESIONS DEPENDENT UPON DISOKDEKS OEIGINATING IN THE 
SECKETOPvY AND EXCRETOKY SYSTEMS. 

Temporary diminution of vision with an ojDhthalmoscopic picture of 
optic-nerve congestion has been found as a sequel of jSarotitis. Brundt ^ 
has noticed tortuosity of the veins of the retina. Noyes ^ quotes a very 
interesting case of optic-nerve tumor seen by Liddell in a young woman of 
twenty years, which first manifested itself by dimness of vision five months 
after a protracted attack of mumps, followed by exophthalmus and blind- 
ness six months later. " The patient was in good health five years later, 
with no return of the growth." Metastatic choroiditis is also said to follow 
the disease sometimes, this condition being most probably the result of 
embolic infarction with resultant localized inflammation. 

Very rarely retinal changes indicative of embolism have been noted in 
association with tonsillitis : Von Graefe is said ^ to have once seen such a 
case. 

Gastric hemorrhage, as, for instance, in Asiatic cholera or in any organic 
lesion of the stomach, may give rise to sudden loss of visual power, just 
as might occur in any other form of hemorrhagic dyscrasia. Galezowski * 
claims to have seen grave disturbance of vision following atrophic changes 
in the optic nerve from gastric troubles ; asserting improvement of the 
ocular condition by attention to the stomachic disorder. 

Hepatic disease, especially of the icteric type, not only produces con- 
junctival discoloration and xanthopsia from bile-pigment deposition, but 
may also give an ophthalmoscopic picture of apparent yellowish discolora- 
tion of the blood of the retinal and choroidal vessels. Jaeger has seen 
this latter condition, which Gowers believes to have been merely an appear- 
ance caused by the tint of the media. Both Junge ^ and Buchwald ^ have 
noted instances of retinal hemorrhages in organic disease of the liver : these 
hemorrhages are believed by Litten^ to be present only in cases of jaundice. 

Intestinal disease associated with general wasting and blood-impoverish- 
ment from local hemorrhages or profuse diarrhoea is at times productive of 
blindness, as noted in Ziegler's case ® of a man who died after a severe 
duodenal hemorrhage, where ophthalmoscopic symptoms of thrombosis were 
seen ; in Schweigger's instance,^ where the optic disks were pale and 
" cloudy," followed by degenerative changes ; and in Von Graefe's case ^^ of 
increasing pallor of the nerve-head and lessening of retinal-artery calibre : 

1 American Journal of the Medical Sciences, 1886. 

2 A Text-Book on Diseases of the Eye, 1890, p. 668. 

^ See Gowers, Manual and Atlas of Medical Ophthalmoscopy, 1882, p. 250. 
* Journal d'Ophtalmologie, March, 1872. 

5 See Gesammelte Schriften (Miiller), 1874. 

6 Berliner Klinisehe Wochenschrift, xvii. 

' Deutsche Medicinische Wochenschrift, 1882, S. 179. 

8 Fortschritte der Medicin, 1887. 

9 Hand-Book of Ophthalmology, 1878, p. 544. 

1° Ergebnisse der Untersuchung mit dem Augenspiegel, 1876. 



208 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

or it may be caused by irritants, such as impacted faeces, as seemingly, 
though doubtfully, shown in Wishart's case,^ where a nine-year-old boy 
was made completely blind in the left eye for some months " by a loaded 
state of the bowels," the patient being cured by clearing the alimentary 
canal f or by the presence of worms, as related by Vandermonde,^ in which 
instance a girl is said to have lost both vision and speech, or, again, where 
strabismus and " amaurosis" were doubtfully clue to the presence of ascaris 
lumbricoides, as in the case mentioned by Hogg.* It is also of interest to 
mention Immermann's adult case,^ where a patient, believing himself to 
have a tape-worm, took such enormous doses of cathartics as to bring on 
exhaustion from excessive diarrhoea. There was no intestinal hemorrhage. 
At first ophthalmoscopic signs were negative, though optic atrophy soon 
manifested itself. 

The blindness which rapidly takes place does not generally ensue until 
several days after the loss of blood : this fact militates very much against 
the belief in mere aneemia as the causative factor, and possibly suggests, as 
Von Graefe^ taught, that it is in a measure dependent upon some dis- 
turbing process in the optic nerve itself. Moreover, as shown by the same 
author,^ other signs of anaemia were not present in such cases. In fact, tlie 
whole subject is still sub jitdice, and until more accurate clinical studies 
have been made, with proper post-mortem examination, answer must be 
looked for not only in the vascular but also in the nervous system. 

As can be readily understood, no special treatment is of any value, 
except in the prevention of rare local complication. All efforts should 
be directed towards the amelioration of the general condition and the 
removal of the exciting cause. 

In many cases of organic renal disease, no matter of what variety, both 
the choroid and the retina share in the general vascular disturbance found : 
especially is this true of the interstitial form of inflammation. While it is 
certain that the cirrhotic kidney is eminently a disease of middle adult age, 
it must not be forgotten that instances of this condition have been reported 
in the young. Moreover, as Tyson ^ has shown the powerful influence 
of heredity as a causative factor, and cites a remarkable grouping of related 
cases, in which it is noted that not only a twenty-year-old brother of his 
patient had Bright's disease for six years, but also that two children of an- 
other brother had the disease when respectively four and seven years of 
age, this factor must not be forgotten. 

1 Edinburgh Medical and Surgical Journal, xxiv. 64. 
^ Hocken, A Treatise on Amaurosis, 1842, p. 127. 
^.Journal de Medecine, tome x. 

* British Medical Journal, July 21. 1888. 

* Deutsche Medicinische AVochenschrift, 1887. 
^ Arehiv fur Ophthalmologic, xii. 2, S. 149. 

' Ibid., vii. 1, S. 150. 

® A Treatise on Bright's Disease and Diabetes, 1881, p. 161. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 209 

Be the initial pathology of the disease what it may, — lesion of the 
ganglionic centres ^ or changes in the vascular intima,^ — it is certain that 
in the chronic form there are localized changes through the entire blood- 
vessel system which lead to degenerative changes of a fatty nature. 

In spite of the fact that Brailey and Edmunds^ have found constant 
alterations in the retinal vessel walls where there were no apparent ophthal- 
moscopic changes before death, it must be conceded that these pathological 
pictures can be nowhere better seen ante mortem than in the retina. The 
membrane laid open to the careful ophthalmoscopist will frequently show 
alterations and peculiarities of appearance that will enable a competent 
observer to note them as pathognomonic. Care should be taken to lay 
sufficient stress upon minute and apparently insignificant changes. The 
writer has a distinct recollection of a young girl of eighteen, supposed to have 
been suffering from general cold, who was sent to him from one of the wards 
of a large general hospital into the ophthalmic dispensary service for the 
purpose of ordinary ophthalmoscopic study. In each macular region he 
discovered a few very faint and questionable flecks and points, which 
seemed to him to be sufficient to excite grave suspicion of renal disease. 
Upon so informing the attending physician, he was rewarded with a scep- 
tical shrug of the shoulders. Careful examination and re-examination of 
the urine, with negative results, made the writer more and more uncom- 
fortable. Six months later, he had the great satisfaction — scientific, at least 
— to receive a note of the result of an autopsy upon the patient, which had 
become necessary by reason of an uncontrollable attack of uraemia, — gran- 
ular kidneys, with cardiac hypertrophy.* 

Roughly, we should generally expect to find evidences of early oedema, 
points and areas of fatty degeneration, hemorrhagic extravasations, and 
even true neuro-retinitis, with consecutive atrophy, in all manner of varia- 
tions and intensities. At first one or more of these conditions is so marked 
as to cause some authors to designate it as the peculiar form of retinal 
change, but later in the affection the other conditions begin to show them- 
selves, and even outbursts, as it were, may give rise to sudden attacks of 
neuro-retinitis with hemorrhagic extravasation: again, the inflammation 
of the nerve-head, with its immediate consequences, may appear primarily, 
and mislead an observer who does not take the precaution to search 
the entire fundus for other related macroscopic changes. The star-like 
radiate patches so generally seen in the macular region should be carefully 
searched for in every suspected instance. Local atrophic changes now 
appear, vessel-calibre lessens still more, vascular walls become more thick- 

1 See Da Costa and Longstreth, American Journal of the IMedical Sciences, July, 
1880. 

■'' A. V. Meigs, Transactions of the College of Physicians, 1888, p. 411. 

2 Transactions of the Ophthalmological Society of the United Kingdom, p. 14. 

* Gowers (Medical Ophthalmoscopy, 1882, p. 184) mentions the rarity of early retinal 
changes without alhuminuria in granular kidney-disease. 
Vol. IV.— 14 



210 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

ened and more opaque, blood-supply diminishes, the nerve becomes more 
pallid and shrunken, and the fatty degenerations pass away, until at last 
the entire color of the fundus pales, and the ground assumes an appearance 
of optic-nerve atrophy with degeneration. Usually this stage is seldom 
reached, the patient, as a rule, rapidly succumbing, as shown by C S. Bull,^ 
to the general disease after the retinal changes of " chronic endarteritis" 
have been made sufficiently gross to be visible by the ophthalmoscope. 

At times the choroid may be involved, showing atrophic patches 
from hemorrhages produced by breakage of the choroidal vessels. Ac- 
cording to Gowers,^ Poncet has figured " a peculiar choroid degeneration of 
the vessels of the choroid in old cases of albuminuric retinitis," which con- 
dition leads on to thickening of the tissue of the choroid. Liebreich {loe. 
Gvt.) has called attention to changes in the epithelium, appearing as " small 
angular gray spots of pigment," these being grouped, and " appearing first 
in the periphery." 

If careful inquiry be not made into associated symptoms, and special 
attention not drawn to a few diiferential points, the ophthalmoscopic symp- 
toms may at times be confounded with those that are dependent upon other 
causes, especially cerebral disease. 

Treatment, which of course is to be directed towards the hygiene, etc., 
of the general system, need only be supplemented by protection of the 
irritated organs of vision from undue exposure and strain. 

In the acute form of the disease, where a single blow, as it were, from a 
renal congestion alone, without involvement of the arterial system itself, 
apparently causes disk-choking with a few isolated " plaques," or where 
sudden blindness ensues with no evident intraocular lesion, it is most 
probable that either the presence of nitrogenous matter in the blood, with 
consequent ursemic poisoning, acting locally upon the optic-nerve and 
retinal elements or upon the visual centres of the cortex themselves, or 
causing simple oedema from watery extravasation in the blood, is the direct 
cause of the conditions. This is the form of intraocular disturbance 
from nephritis so generally found as a factor in the various exanthemata 
and general dyscrasise of children, rendering it, as can be easily imagined, 
the most likely form of retinitis to be associated with childhood. For- 
tunately, however, it apparently much more rarely affects the optic nerve 
and retina than the chronic variety, though it is most probable that were 
the eye-grounds of all the children affected with the various dyscrasise and 
exanthemata to be studied in a routine manner, there would be found a defi- 
nite amount of retinal and optic-disk oedema in every case of any moment, — 
an amount which could be realized only after long experience and study 
among such cases, — an objective symptom which, by long training of the 
clinician, might often be of immense collateral advantage in deciding the 

' Transactions of the American Ophthalmological Society, v. 190. 
2 Medical Ophthalmoscopy, 1882, p. 190. 



PHOTO. XIII. 




Acute Nephritic Retinitis. (Gowers, Medical Ophthalmoscopy, 1882.) 
PHOTO. XIV. 




Chronic Retinal Changes in Albuminuria. (Gowers, Medical Ophthalmoscopy, 18S2.) 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 211 

question of the gravitj of the special disease under care at the time. 
Transient decreases of vision, too, expressive of either cortical, retinal, or 
even conducting-fibre oedema or irritation, may be of value in the question 
of prognosis and treatment. Ophthalmoscopic signs of optic-nerve and 
retinal irritation should be sought in every such case. That they are 
present in the majority of instances there can be no logical doubt, and were 
they searched for in every case, finer differentiation of retinal and optic- 
nerve disorder would be better known. 

Here the treatment of the local symptoms, which must, of course, be 
directed towards the general condition of the patient, must, as can be 
easily understood, be both heroic and prompt. In every instance Tyson's 
words^ should be borne in mind : " There is no doubt that many cases of 
acute nephritis recover while the conditions of rest, quietude, and icarmth 
are maintained." 

The first of the accompanying monotints, taken from Gowers, furnishes, 
in the author's words, ^ " a good example of the diffuse retinitis of Bright's 
disease occurring in the last period of chronic, supervening an acute, ne- 
phritis." The case illustrated by the secoud monotint presents ^ a typical 
example of the two forms of amblyo])ia of Bright's disease : 1, ursemic 
amaurosis, sudden in onset, accompanied by other evidence of uraemia, soon 
passing, and unattended by visible chauges in the fundus oculi ; 2, am- 
blyopia due to the special changes in the retina, gradual in onset, persistent, 
increasing. The retinal changes could be followed from their commence- 
ment, and ran a subacute course. It is noteworthy that congestions of the 
disk, hemorrhages, and small, soft-edged patches were the earliest appear- 
ances, and preceded the zone of dots around the macula. 

Davidson * reports a most instructive case of renal retinitis with total 
detachment of the retina (very much like Anderson's case described under 
the paragraph upon Rubeola) in a fourteen-year-old girl. The urine, which 
failed to reveal casts, was albuminous. Each fundus gave characteristic 
lesions of renal disease. Upon the increase of albumen, blindness from 
retinal detachment came on. Death followed after a convulsive seizure one 
month later. Upon post-mortem examination, botli kidneys were found to 
be contracted, that of the right side being extremely atrophic and weighing 
but one ounce. Both capsules were adherent, leaving a granular surface. 
Granular changes in the cerebrum were also visible. 

It is exceedingly doubtful M^iether Mooren's statemeut^^® that when 
" chronic skin eruptions have their seat in the scalp they favor the occur- 
rence of retinitis by maintaining a constant hyperaemia of the meninges," 

1 A Treatise on Bright's Disease, 1881, p. 113. 

2 Medical Ophthalmoscopy, 1882, p. 323. 

3 Loc. cit., p. 326. 

* Transactions of the Ophthalmological Society of the United Kingdom, 1881, p. 57. 
° Ophthalmologische Mittheilungen, 187-1. p. 93 ; quoted by Xorris, in A Practical 
System of Medicine by American Authors, vol. iv. 



21 2 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

can be fully accepted. Gowers ^ believes that " if such a sequence occurs, 
it is possibly by the production of a local orbital cellulitis." 

Before any definite opinion can be given as to the probability of the 
relationship between the two conditions, more data are necessary. The 
co-operation of those interested in dermatology will be of great assistance 
in obtaining proper statistics upon this all-important though as yet extremely 
vague subject. 

LESIONS DEPENDENT UPON DISORDEPvS ORIGINATING IN THE 
GENEPvATIVE APPAPvATUS. 

As the physiological action of the generative system remains inert 
until puberty, it is seldom, if ever, that we find any ophthalmoscopic symp- 
toms which can in any way be said to have relation with the sexual appa- 
ratus before the adolescent period of life. At this time, however, the whole 
being changes, and every portion of the organism seems to enter into pro- 
found relationship with the generative health and function of the individual. 
The difference of mature development and the peculiarities in the activity 
of the sexual organs of the two sexes seem to exert special mysterious 
influences upon ophthalmic symptomatology ; these being by far more 
profound in woman than in man. 

Disorders of Menstruation. — In spite of Allbutt's inability to associate 
any ocular disturbance with menstrual derangement, there can be no doubt 
that disorders of menstruation are not infrequently the cause of retinal irri- 
tation and optic-nerve inflammation. Kollock ^ gives a brief account of 
a number of cases where, besides asthenopia, ocular pains, etc., which oc- 
curred during female puberty, retiuo-choroiditis appeared. Norris^ cites 
an instance in a thirteen-year-old girl, where, in addition to the ordinary 
external congestion, with inability to use the eyes, "the retinal fibres wer- 
swollen and oedematous, hiding the outlines of the disk, while the lymph- 
sheaths of the retinal vessels at their point of emergence from the disk pre- 
sented an almost snow-white appearance," Moreover, he says, " the disks 
and the retinse have never quite recovered a normal appearance." Gowers * 
says that " in chronic menstrual irregularities optic neuritis of chronic 
course has been found, and occasionally other disturbances, such as retinal 
hemorrhages." The writer has at the present time a most interesting ex- 
ample of sudden intense neuro-retinitis, with great reduction of vision and 
limitation of color fields, appearing in a young amenorrhoeic girl, which 
rapidly subsided, leaving both fair central and excentric vision, through 
prompt re-establishment of the menstrual function. H. H. Derby ° cites an 
instance of an intense monocular neuro-retinitis which appeared in a twelve- 

1 Medical Ophthalmoscopy, 1882, p. 222. 

2 Gaillard's Medical Journal, June, 1888. 

* Pepper's System of Medicine, vol. iv. 

* Medical Ophthalmoscopy, 1882, p. 221. 

^ Transactions of the American Ophthalmological Society, 1888, p. 106. 



PHOTO. XV. 




Partial Absorption of Hemorrhagic Opacities in the Vitreous. (Powers, Transactions 
of the Ophthalmologieal Society of the United Kingdom, 1888.) 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 213 

year-old girl who had never meustruated. In concluding the report of his 
case, he says, " That the optic neuritis bore some relation to the efforts of 
nature to establish the catamenial period seems more than probable." In 
most of the cases the fundus-chauges are very slight, and would probably 
pass unnoticed by a careless or an incompetent ophthalmoscopist. As the 
case advances, however, the conditions become more marked, and may event- 
ually lead to actual inflammation and degeneration. Thaon^ records a well- 
marked case of neuro-retinitis with " numerous white patches along and 
superjacent to the vessels, with some large muscse in the vitreous. Vision 
was abolished in the upper third of the field. Treatment directed to the 
restoration of the menses was followed in this case by great improvement, 
if not perfect recovery." Sometimes jDrofuse intraocular hemorrhages appear 
and reappear at every catamenial ejDoch. Wardrop ^ credits Pechilini with 
having seen " a young woman who had amaurosis during a suppression of 
the menstrual discharge, which was removed the moment menstruation re- 
turned." St. -Yves ^ quaintly says that " it generally attacks maids that are 
not regular." Dor relates * a most instructive case, whilst Power {supra) 
gives an exquisite chromo-lithograph of a similar condition in a thirteen- 
year-old girl suffering from menorrhagia. The accompanying sketch shows 
the condition of the fundus " after the opacities in the vitreous occasioned 
by the breaking up of the blood-clot behind the iris had broken ujd and 
diffused through the vitreous." 

Prognosis is favorable in due proportion to the amount of resultant 
pathological change. 

In the majority of instances the treatment must be given to the gynae- 
cologist, leaving dangerous local complications to the therapy of the oph- 
thalmologist. In the hands of the writer, varying proportions of the ingre- 
dients of Dewees's mixture have proved of great advantage in a few cases 
of dysmenorrhoea and amenorrhoea with ocular symptoms that he has seen. 

As a matter of curiosity, it may be worth while to state that Finkel- 
stein ^ asserts that a concentric narrowing of the field of vision for both 
form and color takes place during the ordinary menstrual period, which 
reaches its greatest degree during the height of the epoch, this being accom- 
panied at times with faulty perception of yellow for green, and a slight 
diminution of central vision without change of refraction. 

Masturbation. — This vice, which is probably of greater frequency in the 
male sex, is undeniably shown to be at times associated with optic-nerve 
and retinal change. Cohn's^ seven cases, three of which were girls, gave 

^ These de Paris, reported by Power, in Transactions of the Ophthalmological Society 
of the United Kingdom, 1888, p. 14. 

^ Essays on the Morbid Anatomy of the Human Eye, 1818, ii. 171. 

3 A New Treatise of the Diseases of the Eyes, 1741, p. 194. 

* Recueil d^Ophtalmologie, 1884, p. 164. 

° Inaugural Dissertation, St. Petersburg, 1887. 

« Archives of Ophthalmology, 1882, p. 428. 



214 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

pronounced photopsise as subjective evidences of retinal irritation, these 
symptoms rapidly subsiding upon cessation of the habit. Fitzgerald ^ 
gives the details of the cases of two young women who were victims of 
the habit, in both of whom the optic disks were slightly hazy, associated 
with pallor, which condition was followed by "■ total atrophy" of the nerve 
in one of the cases ; whilst Power ^ has seen with MacKinlay a hemor- 
rhage upon or in the retina in a nineteen -year-old lad, whose only causative 
symptom seemed to be frequent masturbation. 

The diagnosis, which is often extremely difficult, especially in the female 
sex, is to be determined by allied symptoms. In contradistinction to the 
results of Fitzgerald's and Power's cases, the prognosis ordinarily may be 
said to be favorable. Treatment should be directed towards the moral and 
physical hygiene of the patient, and care should be taken in all inveterate 
cases to institute search for mechanical irritants, such as phimosis, vulvitis, 
vaginitis, etc. 

The blindness of hysteria^ is but another among the multitudinous 
real and fanciful symptoms which are so frequently spoken of by a most 
unfortunate class of subjects. As with all other forms of disease which are 
more or less closely related with the condition of the sexual apparatus, the 
male sex is certainly freer than the female, although, as Charcot says,* hys- 
teria in the male is far from being rare. Harlan^ gives the details of the 
case of a boy of eleven years who persisted in supposed blindness of one eye 
for more than eighteen months. St. John® notes an almost identical instance, 
though only of five weeks' duration, in a ten-year-old boy with decided 
neuropathic antecedents. Another case by Harlan^ of ten years' duration 
had its exciting cause in the assertion of an ophthalmic surgeon of a " paral- 
ysis of the optic nerve" from traumatism ; the whole delusion being dispelled 
by a few moments' careful ophthalmic examination. Moore^ gives an in- 
stance of a fifteen-year-old lad with blindness in the right eye, which 
occurred after disappointment at school. Under ether and electricity re- 
covery was both rapid and permanent. Schweigger^ associates the mon- 
ocular type, as just given, with unconscious psychic deceit upon the part of 
the subject. Glascott^" and Snell,^^ under the title "Amaurosis fugax," each 
describe instances of the bilateral variety. Griffith ^^ reviews the subject 



1 Transactions of the Ophthalmological Society of the United Kingdom. 

2 Ibid., 1888, p. 7. 

^ Although it is doubtful whether this functional disorder should come under the above 
category, yet, as the associated conditions are so symptomatic of sexual derangement, it has 
been thought best to place it there. 

■* Clinical Lectures on Certain Diseases of the Nervous System, 1888, p. 10. 

^ American Journal of the Medical Sciences, October, 1873. 

6 Transactions of the American Ophthalmological Society, 1889, p. 330. 

' Op. cit., p. 328. * Medical Chronicle, August 2, 1889. 

" Klinische Monatsblatter fiir Augenheilkunde, November, 1881. 

1" British Medical Journal, 1879. " Ophthalmic Eeview, 1882. 

1'-' Transactions of the Ophthalmological Society of the United Kingdom, vii. 292. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 215 

and adds some clinical data. Both Jackson^ and Marlow^ refer to cases in 
the male sex ; the former's case being that of a delicate colored lad of twelve 
years. Charcot^ describes a variety in a boy of sixteen years, in whom, in 
association with anaesthesia in patches and blunting of hearing, smell, and 
taste on the left side, there was double contraction of the visual field, more 
pronounced on the right side, upon which side the patient did not dis- 
tinguish violet ; the fields for red were larger than those for blue. In 
spite of all treatment, the convulsive crises, the hysterical stigmata, and 
the sensorial and sensitive anaesthesias continued. A second and some- 
what similar instance, in an eighteen-year-old boy, is cited by the same 
author.* 

In the female these symptoms are more common, as has been incon- 
testably shown at La Salpetriere, at which place Charcot finds frequent 
coincident or causative ovarian derangement. Applying the significance of 
Weir Mitchell's expressive w* ords, that " the symptoms of real disease are 
painted on an hysterical background," ® to the reasoning of the causation 
of the many curious subjective ocular changes seen in such cases, the special 
symptomatology of the organ as seen in ordinary disease may be said to be 
absolutely and entirely given. Varying contractions and perversions of the 
visual fields, temporary losses of perception of certain colors, marked lower- 
ing of direct vision, appear, — all probably, in a measure, the result of sensory 
fatigue in association with the ordinary motor impairment of both the intra- 
ocular and the extraocular series of muscles. Even retinal hypersesthesias, 
wath colored phosphenes at times, in conjunction w'ith the almost innumer- 
able variety of clonicisms, frequently occur, whilst crossed amblyopias and 
heraiansesthesias seemingly appear. Many cases could be given, but it hardly 
seems necessary to cite in detail what so many neurologists and ophthalmolo- 
gists see so frequently. An interesting case, however, of this character in a 
young girl has recently come under the observation of the writer, in which, 
in addition to the ordinary symptoms of greatly-lowered vision for form and 
color (the former of which could not seemingly be improved by careful cor- 
rection of an existent refraction-error) and the general characteristic condi- 
tions, there Avas a peculiarity of the fields of vision, which at first seemed to 
tally with the so-called " perversion of color-fields" so frequently noted 
by various authors, but after repeated and painstaking trials at several 
hours' intermission proved to be nothing more than an abnormal fatigue of 
the sensory structures, by which at every trial any order of fields could be 
obtained, — this order always coinciding in extent with the first colors tried. 
One day the green, which was tried first, gave a much larger area than 
white, blue, yellow, and red, in the order named ; on the following morning 

1 Transactions of the American Ophthalmological Society, 1888, p. 85. 

2 New York Medical Journal, February 9, 1889. 

^ Clinical Lectures on Certain Diseases of the Nervous System, 1888, p. 131. 

* Op. cit., p. 143. 

= Quoted by Gowers, Manual of Diseases of the Nervous System, 1888, ii. 907. 



216 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

green was made the smallest area and red much greater in extent than any 
other color-field, simply by trying the green last and the red first. In other 
words, the color first tried gave the largest area. On the third and fourth 
days the colors were tried at fifteen-minute intervals, at which examination 
the usual order of white, yellow, blue, red, and green was followed, though 
in every instance the areas were more and more contracted, just as the direct 
vision for form and for color was found more greatly impaired after re- 
peated trials. Fleeting scotomata for every color could be obtained in any 
part of the visual fields, but at no time were the colors miscalled or con- 
founded with one another. The questions thus arise. May not many of 
the so-called perverted color-fields in this disease be simply due to improper 
field-taking, and cannot the order of sequence of color-areas be obtained 
much more frequently by carefulness to avoid sensory fatigue ? In a second 
though still uncertain case, seen in the practice of Dr. Robert M. Girvin 
through the courtesy of Dr. John H. Musser, in which there was blindness 
upon the left side, with a perverted order of irregularly contracted and 
exceutric color-fields upon the right side, the yellow^ was persistently desig- 
nated as " pale green" in every part of its visual field except at one small 
point in the centre of the combined color-areas up and out, where it was 
properly named. In this case the retina of the left (blind) eye showed a 
slightly oedematous condition, with some tortuosity of its veins, as described 
by Landolt. De Schweinitz^ also reports "a somewhat distended and 
slightly tortuous retinal vein, with undue prominence of the central lymph- 
sheaths," in a sixteen-year-old girl, with complete hysterical analgesia and 
aphonia. In this case the visual fields were normal. 

In two cases recently studied through the kindness of Dr. William 
Goodell, careful perimetric examination showed more than one-thirtieth re- 
duction of both form- and color-vision from normal, this in each instance 
being more pronounced upon the left side. The same is true of another 
example of the same type seen in conjunction Avith Dr. AVharton Sinkler. 
All three cases were in young female adults. In no instance was there any 
perversion of the order of the fields of vision. 

From these groupings it can be seen that with the concomitant symp- 
toms the diagnosis is comparatively easy, though when the manifestations 
are limited to the ocular apparatus alone the disease becomes difficult to 
discover. Enough, however, has been said to show that the very muta- 
bility of the special symptoms affords an excellent criterion for the recog- 
nition of " that domestic demon which has produced untold discomfort in 
many a household, and, I am almost ready to say, as much uuhappiuess as 
the husband's dram."^ 

With the exception of retinal- vessel dilatation and oedema, true objective 

^ This is both remai'kable and highly symptomatic, as being opposed to the ordinary 
color-loss seen in organic change of the second nerve. 

^American Journal of the Medical Sciences, November, 1889. 

^S. Weir Mitchell, Wear and Tear, or Hints for the Overworked, 1874, p. 29. 



OPHTHALMOSCOPY : SYAfPTOMATIC DISORDERS. 217 

fundus-changes have never been noted, although it may be fair to presume 
that in the hystero-epileptic form of the disease, where the seizures have 
been both many and severe, physical alterations like those so constantly 
found in old epileptics (even in young subjects) may become visible. 

No absolute data can be given as to the prognosis. Some cases recover 
vision spontaneously without any assignable cause ; others are almost 
momentarily freed from this disturbance by profound psychic impression ; 
others, again, linger for a long time without any apparent gain, in spite of 
all hygiene and judicious care ; whilst a number seem pushed, as it were, 
into absolute darkness, to remain forever blinded. 

All that contributes to the general welfare of the patient (not forgetting 
Dr. S. Weir Mitchell's highly successful " combination of therapeutic meas- 
ures," ^ which " consists in an effort to lift the health of patients to a 
higher plane by the use of seclusion, which cuts off excitement and foolish 
sympathy ; by rest, so complete as to exclude all causes of tire ; by mas- 
sage, which substitutes passive exercise for exertion ; and by electrical mus- 
cular excitation, which acts in a somewhat similar manner to massage, and 
with it by depriving rest in bed of its essential evils," ^ in any case that has 
resisted the advantages of out-door exercise in a new environment) should 
be conscientiously tried, and offctimes apparently grave ocular symptoms will 
disappear as the physical and the moral tone of the patient improve. Sim- 
ulation of both the conscious and the unconscious types can be readily 
detected by repeated and careful testing. 

LESIONS DEPENDENT UPON SPECIAL DYSCKASI^. 

In enteric or typhoid jever, which is especially an affection of early adult 
life and adolescence, ophthalmoscopic lesions are not wanting. Hutchinson ^ 
gives an instance of a boy who developed double optic neuritis two or 
three weeks after an attack of fever which was complicated by marked 
diarrhoea and cephalalgia, — a condition of eye-nerve no doubt due to an 
associated meningitis. Fortunately, however, as Wilson tells us,* " actual 
meningitis is exceedingly rare, notwithstanding the comparative frequency 
of symptoms suggestive of its presence." 

Cases of secondary atrophy without ophthalmoscopic appearances of 
previous inflammation of the nerve-head are on record, as, for instance, the 
interesting one noted by Haddaeus^ and others. The present writer has 
seen a ten-year-old girl in the general wards of St. Agnes's Hospital, who, 
two weeks after the cessation of all active symptoms of typhoid fever Avith- 
.out any seeming complication, showed extremely pallid disks, especially to 
the temporal sides, with marked reduction in the calibre of both the arterial 

1 Lectures on Diseases of the Nervous System, especially in Women, 1885, p. 269. 

2 Op. cit, p. 270. 

^ Eoj'^al London Ophthalmic Hospital Reports, ix. 125. 

* This Cyclopfedia, i. 471. 

^ Klinische jVIonatsbliitter fiir Augenheillvunde, August, 1865. 



218 OPHTHALMOSCOPY: SYMPTOMATIC DISORDERS. 

and venous currents. The query arises, Was a low-grade meningitis the 
mischief-maker in this instance ? 

As cardiac thrombi are present at times, it is not difficult to understand 
how intraocular vascular changes, such as embolism of the central artery of 
the retina or of one of its retinal branches, may at times be found. Gale- 
zowski ^ cites such a case. 

Typhus fever, which is usually mild in children, is not very apt to 
have marked intraocular changes associated with its symj)toms. Where 
optic nerve-head changes have been found, it is most probable that they 
have been either the results of meningeal inflammation or the consequences 
of lodgement of embolic or thrombotic massings : thus, the cases of Chis- 
olm ^ and Teale,^ quoted by Gowers,* probably belong to the former class. 
According to Norris,^ Larionow's statistics of fifty-seven patients with 
typhus exanthematisraus show one instance of neuro-retinitis and two 
cases of contraction of the field of vision. Pepper,^ M-ho has had oppor- 
tunity to study the affection during an epidemic in Philadelphia, says that 
eye-symptoms were very rarely seen. 

Independently of the presence of a definite spirillum in the blood of 
patients suffering from relapsing fever, which of itself may be productive 
of disturbance in the vascular channels of the eye, metastases from splenic 
abscess, septic peritonitis, or even hemorrhagic infarcts from various viscera, 
etc., which are at times found in this disease, may all give rise to profound 
inflammation of the more deeply seated tissues of the uveal tract. Choroid- 
itis with consequent hyalitis, cyclitis with pus in the posterior chamber,^ 
and retinal and optic-nerve complications, may all appear. TrompetterS 
has determined the presence of these conditions in nearly six and a half per 
cent, of over three hundred cases seen by him. 

Scarlet fever, or scarlatina, — the dread disease of the young, — is so apt 
to have renal derangement as one of its symptoms that it is not infre- 
quent to have some form of intraocular expression of the complication. 
More especially is this noticed with the amblyopic form of disturbance, 
where, without warning, at the time of the utmost severity of the attack, 
double blindness suddenly appears, to last but a few days. The ophthal- 
moscope seemingly tells nothing of the cause, except a possible slight ob- 
scuration of the border of the head of the optic nerve. Ebert,^ cpioted by 

^ Traite leonographique, p. 188. 

^ Royal London Ophthalmic Hospital Reports, vi. 214. 

•3 Medical Times and Gazette, May 11, 1867. 

* Medical Ophthalmoscopy, 1882, p. 240. 

^ A System of Practical Medicine by American Authors, vol. v. 

^ System of Medicine, vol. i. 

' Schweigger (Hand-Book of Ophthalmologj^ 1878, p. 419), in speaking of an epidemic 
of recurrent fever which occurred in the Charite Hospital in Berlin, says that there was 
simple unilateral iritis in nearly one-half of the cases. 

8 Klinische Monatsbliitter fiir Augenheilkunde, April, 1880. 

" Veninderuneen des Auirenhinterarundes. 



OPHTHALMOSCOPY : SYMPTOMATIC DISOEDERS. 219 

Xorris\ gives a series of clinical histories of such instances. In the dis- 
cussion of these cases, Graefe^ maizes the important observation that as 
there is always proper motion of the irides to light-stimulus, the lesion 
must be posterior to the quadrigemiua : the symptoms of such a condi- 
tion thus may prove of immense collateral value in the prognosis of vision. 
Pfliiger's note ^ of a ten-year-old child who became gradually blind in three 
days' time three weeks after an attack of scarlet fever, is interesting in 
showing " double papillo-retinitis" without the presence of albumen in 
the urine. In five months sight had returned to almost normal. It is prob- 
able that meningitic inflammation was the cause, as was partially evidenced 
by " considerable headache" during the fever. Bayley * gives the histories 
of progressive failure of sight in two sisters who had uncomplicated attacks 
of scarlet fever. In each instance pigment-massings in the fundus oculi 
were visible, whilst the optic disk is noted as merely "pale." Cases of 
direct implication of the optic nerves, with seeming consecutive atrophy 
from descending optic neuritis, are on record. More rarely, inflammatory 
changes in the choroid, with liquid effusion between the choroid and the 
retina, giving rise to grave intraocular destruction, have been noted. 

In all these latter forms of ocular disease the prognosis is truly grave. 
Lubinski^ is said to have found evidences of irido-cyclitis Avith vitreous 
opacities in twenty-two out of six hundred and forty patients. The ocular 
affection occurs as a late sec^uela of the fever. In the lighter form hyper- 
emia of the disk is noted. All the cases seen were in male adults.^ Alter- 
ative and absorbent treatment, with attention to the general hygiene of 
the little patient, is all that can be judiciously recommended for the preser- 
vation or improvement of the remaining sight. 

In marked cases of diphtheria, especially where multiple paralyses 
ensue, ophthalmoscopic pictures of grave optic-nerve disease with consecu- 
tive atrophic changes have been seen. Bouchut '' has found such instances, 
one of which was unilateral in type. Gowers ^ says, " The congestion and 
oedema are usually bilateral, but may be more intense on one side than on 
the other." In partial confirmation of this statement, the writer has pub- 
lished ^ an account of a twelve-year-old boy who, five years after an attack 
of diphtheria and paralysis which confined him to bed for three months,^"" 
whilst presenting an ophthalmoscopic appearance of double chorio-retinitis 

^ Pepper's System of Medicine, vol. iv. - Quoted by Norris. 

^ Archiv fiir Ophthalmologie, vol. xxiv., mentioned in Gowei-s's Medical Ophthal-. 
moscopy, 1882, p. 243. 

* The Lancet, September 15, 1877. 

5 Wjestuik Ophtalmologie, 1887. 

^ Thomson and Gould, Annual of the Universal Medical Sciences, vol. iii., 1888. 

^ Quoted in Gowers's Medical Ophthalmoscopy, 1882, p. 249. 

8 Medical Ophthalmoscopy, 1882, p. 249. 

^ Transactions of the American Ophthalmological Society, 1887. 

^^ During the time of his illness he was unable to speak, and his eyesight became bad, — 
the latter condition persisting. 



220 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

with partial degeneration of the optic nerve, associated with curious lymph- 
extravasation into the retina and vitreous, more pronounced on the right 
side, gave but one-fiftieth of normal vision with the right eye and nearly 
one-fifth with the left. At that late time the patellar tendon reflexes were 
almost abolished. An examination of the urine failed to reveal any 
abnormal deposits. 

It is probable that most of the fnndus-lesions sometimes met with in 
rubeola are dependent upon meningitis or some other form of cerebral com- 
plication. Wadsworth^ reports three such instances. Stephenson ^ cites a 
case of double optic neuritis which was accidentally discovered in a four- 
year-old boy who had just recovered from an uncomplicated attack of 
measles. Whether there was any causal relationship between the two in 
this case it is impossible to say, although there was an entire absence of 
any other apparent organic disturbance. Coggin^ gives the history of 
several cases. He says, ^' The lesion is supposed be be a circumscribed 
basal meningitis, and non-tubercular, though rarely tubercular deposits are 
present." Both Von Graefe * and NageP give cases — especially the latter 
— which are expressive of cerebral disturbance. 

Should nephritis set in, the fuudus-lesions may become quite pro- 
nounced : thus, a rare case of isolated retinal detachment from subretinal 
effusion subsequent to a severe hemorrhagic neuro-retinitis is reported by 
Anderson ^ as having been seen in a six-year-old girl who was suffering 
from chronic nephritis, which seemed to follow an attack of rubeola, with 
subsequent bronchitis and " consumption of the bowels," at eighteen months 
of age. Uraemia terminated the patient's life three months after the oph- 
thalmoscopic signs became manifest. The necropsy revealed advanced 
fibroid contraction of the kidneys. The case is Avorthy of record not only 
on account of its comparative rarity, but also as most probably having had 
the exanthem as its starting-point. 

Here, as shown in all the acute exanthemata, the solution of the whole 
problem is to be found in pathological changes which affect the nervous and 
vascular systems. 

In view of Edwards's observation ^ that he has seen " one instance of 
tubercular meningitis develop as a complication of rubella^' (rotheln), fundus- 
oculi lesions indicative of this condition may at times be expected. As 
renal disturbance has also been met with by Curtman (loo. eit), ophthalmo- 
scopic expression of such an occurrence may not be wanting; in fact, all 
the intraocular expressions of other exanthemata, which are visible to the 



' Boston Medical and Surgical Journal, 1880, p. 636. 

■■* Transactions of the Ophthalmological Society of the United Kingdom, viii. 150. 

■^ American Journal of Ophthalmology, January, 1890. 

* Archiv fiir Ophthalmologie, xii. 2, 138. 

^ Behandlung der Amaurosen, S. 24-30 (quoted by ISTorris). 

^ Transactions of the Ophthalmological Society of the United Kingdom, 1888, p. 141. 

^ This Cyclopedia, i. 697. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 221 

ophthalmoscope, may be safely asserted to have proper placing among the 
possible ophthalmic symptoms seen from time to time. 

The sudden blindness which sometimes appears during the convulsive 
stage of pertussis is a priori generally associated with hemorrhagic extrava- 
sation into the interior of the eye from vessel-rupture during a paroxysm. 
Case III. of Landesberg's series^ most probably belongs to this group- 
ing. Knapp^ found all the symptoms of " ischsemial retinse" in a three- 
year-old boy who suddenly became blind during an attack of whooping- 
cough. Curiously, " both pupils, however, responded promptly to changes 
of light." A double paracentesis seemed to restore both optic nerve and 
retinal circulation to a sufficient degree not only to give objective signs of 
betterment, but even to allow the patient to recognize ordinary objects. 
Six weeks after the operation the child died from lobular pneumonia : a 
confirmation of a remark made to the observer by Prof. Loomis, of New 
York, who informed him " that blindness in whooping-cough had been ob- 
served, but almost exclusively in children Avho afterwards died from lobular 
pneumonia." Case I. of Landesberg's list ^ reads very much like a case of 
embolism of one or two of the upper arterial branches in the right retina : 
vision is said to have been restored to one-half of normal. Alexander* 
contributes two examples. The first, which was followed by death, gave 
proper pupillary reaction ; here cerebral oedema 'between the occipital lobes 
and the quadrigeminate bodies is supposed to have been the cause. The 
second showed optic neuritis with consecutive partial atrophy. In this 
instance the irides were immobile. Meningitis is named as the cause. 

Except by direct infection or extension of purely local changes, deep 
lesions of the eye as complications or sequelae of variola are very infrequent. 
Gowers^ instances a man of fifty who had atrophy of the right optic disk 
dating back to an attack of small-pox at twelve years of age. When seen, 
the patient exhibited some general and local signs of ataxia. He also cites 
Leber® as observing diffuse neuro-retinitis during the stage of drying of 
the eruption. 

Varicella, the most benign of all the acute exanthemata, fails to 
present any lesion of the optic nerve or the intraocular tunics except in the 
gangrenous variety of the disease. In this class of cases Hutchinson ^ has 
seen loss of sight from purulent irido-choroiditis, a condition no doubt de- 
pendent upon metastasis of pathogenic material from some infected organ, 
causing the formation of a local inflammation somewhere in the uveal tract, 
with consequent abscess. 

1 Medical and Surgical Keporter, 1880, p. 249. 

^ Archives of Ophthalmology and Otology, iv. 448. 

3 Op. cit, p. 248. 

* Deutsche Medicinischc Woehenschrift, No. 11, 1888. 

'= Medical Ophthalmoscopy, 1882, p. 348. 

« Op cit., p. 244. 

^ Quoted by Jennings in vol. i. of this Cycloptedia, p. 763. 



222 OPHTHALMOSCOPY : SYMPTOMATIC DISOEDERS. 

As mentioned by Hirschfelder in vol. i. of this Cyclopsedia, p. 778, 
" Amaurosis has been produced by retrobulbar abscess," in erysipelas 
both of the face and of the head, this being caused by extension of the 
external inflammation into the tissues of the orbit, with involvement of 
the optic nerve. Both Knapp ^ and Jaeger report cases where the eye- 
grounds presented pictures indicative of thrombosis. In some of the worst 
cases the veins of the orbit become pus-bearing, leading to brain-complica- 
tions, which cause the patient's death. Weiland ^ has had a marked case 
where recovery was extremely slow. At times there is no other decided 
symptomatic evidence of pus- formation in the orbit with extension, or proof 
of pressure from inflammatory material, than a rapid loss of vision. This 
decrease of sight generally begins either both centrally and peripherally, 
leaving the so-called annular field, or centrally alone. In such cases intra- 
ocular changes of consecutive atrophy are apt to manifest themselves ob- 
jectively later.^ Oeller's * case is of much interest. 

The peculiarity of the ophthalmoscopic picture, in every instance, is 
merely indicative of the kind of offending inflammatory material, and is 
dependent upon the amount and position of the pressure-changes. 

As endocardial disease is more prone to appear in the rheumatism of 
childhood than it is in that of adult life, ocular symptoms expressive of 
the complication should be more frequently expected among children than 
among older patients. These changes, as might be expected, belong to the 
vascular type of disease : thus, embolism of the central retinal artery, or even 
choroiditis of the metastatic type, may appear. Direct implication of the 
post-ocular portion of the optic nerve from irritation in the orbit may give 
rise to pressure-signs or inflammation-symptoms in the interior of the eye. 

Not infrequently, when a new or a weakly subject is pushed, as it 
were, into a paludal district, the series of symptoms indicating malaria 
produced by the specific blood-poison are increased by an ocular grouping 
which not only embraces the superficial form of inflammation but also in- 
cludes changes in the deeper and denser motor and sensory nerve-structures 
of the organ. These changes in the eye are probably due either to the pas- 
sage of some of the foreign substance in the blood into the ocular tissues 



^ Archives of Ophthalmology, 1884. 

^ Deutsche Medicinische Woehenschrift, 1887. 

^ Stille (International Encyclopaedia of Sui-gery, Ashhurst, 1881, p. 185) quotes 
Parinaud (Archives Generales de Medecine, June, 1879, p. 641) as saying, "Besides the 
sequelae common to all the forms, there is one that is indeed rare and seems peculiar to 
erysipelas of the face. It is blindness due to an atrophic degeneration of the optic papilla, 
which sometimes affects only one eye, and sometimes both eyes. The impairment of sight, 
when it occurs only in one eye, begins towards the close of the attack, or when the swelling 
of the eyelids has subsided sufficiently to permit them to be raised. When both eyes have 
been involved, the impairment of sight appears not to have been noticed before the com- 
plete subsidence of the erysipelas, and, after varying in degree, to have left a permanent 
defect of vision, sometimes, however, in regard to certain colors." 

* Miinchener Medicinische Woehenschrift, 1889. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 223 

themselves, or to the lodgement of pathological products in such a position 
in the intraocular apparatus as to cause undue pressure upon some impor- 
tant part, with irritation and inflammation of adjacent material. In more 
marked cases brain and spinal-cord disturbances may ensue, the former 
giving rise to complications which make themselves known by various 
peripheral neuroses. Rarest of all these affections is that of the optic nerve 
itself At times its disturbance is made apparent by attacks of transient 
amblyopia, which probably by frequent repetition causes gradual degenera- 
tion of nerve-material. Such symptoms generally manifest themselves very 
soon after a severe attack of the fever, especially if the patient be in a hot 
climate. In these cases the capillary circulation of the optic disk is almost 
or quite gone, leaving the substance very pallid and white. At times the 
retinal vessels are small, whilst limitation of the visual field, even of the hemi- 
anopsic variety, and great diminution of central vision, for both form and 
color, manifest themselves. C. S. Bull ^ describes two such cases in adults. 

In another class of cases, which occurs almost exclusively in the tropics, 
and in which hemorrhagic retinitis with perineuritis exists, the fundus oculi 
shows numerous striated and stellate hemorrhages either situated along 
the larger retinal stems or scattered in small areas between the disk and 
the fovea, the nerve-head itself varying in degree of swelling and serous 
infiltration. De Mussey ^ relates one such instance. 

Mackenzie^ gives the descriptions and drawings of the eye-grounds of 
two young men with the quotidian type of the disease. In each instance 
large superficial hemorrhages were found, the first having a number of 
pin-point opacities scattered about the eye-ground. A third case, of the 
tertian type, in a patient aged eighteen years, also showed hemorrhagic 
extravasation into the retina. In none of the instances was the optic nerve 
very much disturbed. In all the retinal-vessel calibre appeared normal. 

According to Gowers,* Ramorius ® has had the good fortune to study 
the vascularity of the fundus oculi during a series of paroxysmal attacks 
of periodical amblyopia in two cases. During the paroxysm the nerve- 
heads were pallid and the arteries of the retina were thread-like and almost 
bloodless, whilst the veins were nearly invisible. Curiously, this attack 
was accompanied by " great congestion of the face and ears and a sensation 
of heaviness in the head." Other vaso-motor and sensory symptoms were 
present. Quinine rapidly cured both of the cases. 

Accepting Guiteras's conclusiou,^ " that the foci of endemicity of yellow 
fever are essentially maintained by the Creole infant population," and agree- 
ing with his belief^ "that yellow fever in its native haunts is essentially a 

' American Journal of the Medical Sciences, April, 1877. 

2 Journal d'Ophtalmologie, 1872. 

3 Medical Times and Gazette, 1877. 

* Medical Ophthalmoscopy, 1882, p. 247. 

* Annali di Ottalmologia, 1877. 

« This Cyclopii?dia, i. 854. ' Op. cit., p. 857. 



224 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

disease of childhood, the adult native being protected by a previous attack/' 
it at once becomes apparent that the ocular symptoms of the disease, modified 
by the age of the patient and the gross peculiarity of the general symptoms, 
are to be found here just the same as in the adult. 

Although the conjunctival injection and ecchymotic spots are very rare 
in this class of subjects, yet their very presence, just as in older patients, 
may serve to explain in some instances rapid failure of sight as possibly 
caused by intraocular extravasation. In graver cases, though fortunately, 
from the nature of the disease, its pathology, and the age of the patient, 
very rarely, emboli or thrombi from hemorrhagic foci in the cardiac and 
pulmonary cavities may at times appear and give rise to pronounced visual 
and ocular disturbance. Again, temporary blindness and dimness of \'ision 
at the onset of the disease, or pupillary dilatation and extraocular muscle 
enervation seen later in the disorder, as shown by Rush^ to have been 
found in adult cases, may at times be expected in some cases where unusual 
nerve symptoms followed by coma ensue. 

Were the ophthalmoscope employed regularly in every instance of 
the pyretic stage of dengue as seen in children, ophthalmoscopic symptoms 
indicative of cerebral change might at times be manifest. Should endocar- 
ditis or even arthritis appear, intraocular manifestations, as previously 
mentioned in speaking of some of the other fevers and dyscrasise, may 
show themselves. According to Thomas,^ " glaucoma, amaurosis, . . . and 
other evidences of the profound impression of the poison , . . are more 
deserving of attention." 

In cholera, as Xorris says,^ " the retinal arteries are much diminished in 
size, and the veins, although not dilated, are filled w^ith blackish blood." 
Continuing, he tells us that, " owing to the great feebleness of the circula- 
tion, the slightest pressure with the finger on the eyeball produces arterial 
pulse." Von Graefe* has found instances where artificially induced increased 
intraocular tension caused the arterial blood-currents to disappear, this 
being especially noticeable in cases where the cardiac action was so enfeebled 
that the ordinary radial pulsation could not be determined. He has also 
found the otitic nerve head reddish blue in appearance. 

In spite of the declaration of some authors that they have been unable 
to find a special form of retinitis in diabetes, the affection is of such great 
frequency in the glycosuria variety of the disease and the changes are so 
peculiar that there can be no reasonable doubt of the existence of the asso- 
ciation. If it be true, as Ellis ^ says, that both forms of the disorder are 
excessively rare in children, and if clinical results support Fenwick's asser- 

1 An Account of the Bilious Eemitting Yellow Fever as it appeared in the City of 
Philadelphia in the Year 1793, 1794. 

- Quoted hy Matas, this Cyclopa?dia, vol. i. p. 891. 

^ A System of Practical Medicine by American Authoi-s, vol. iv. 

* Archiv fiir Ophthalmologie, xii. 2, 210. 

» A Practical Manual of the Diseases of Children, 1879, p. 157. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 225 

tions^ that when present in early life the disease "is seldom protracted 
beyond tliree or fonr years," and that most patients " die within a year or 
eighteen months," it may be fairly presumed that ocular disturbance should 
be expected in the great majority of such cases, — a presumption that can 
only be made a certainty, however, by painstaking study of every case. 
Rolland^ goes so far as to say that he has never found a glj^^cosuric who did 
not have some visual disturbance. 

In a number of instances there is nothing more than a binocular dim- 
ming of central vision, with the retention of fair peripheral sight, and without 
any appreciable ophthalmoscopic lesion. In others, following this condi- 
tion, the nerve-head generally loses some of its capillarity and appears 
partially atrophic. In some of these cases, as shown by the great disposition 
to hemorrhagic extravasation,^ it is possible that the degenerative changes 
that have been found post mortem in the optic nerve* are the results of 
aneurismal dilatation with breakage of the vessel-walls of the capillaries of 
the optic nerve in such a position as to give rise to the appearance of central 
scotomata. 

In another variety, especially where probable nephritic change has taken 
place, as expressed by the presence of albumen in the urine (though by no 
means invariably), the hemorrhages seem to take place intraocularly ; here 
the ophthalmoscopic picture is totally different : instead of a comparatively 
healthy eye-ground, the retina is puffed and swollen, the disk is hidden, 
whilst numerous hemorrhagic striations in the retina and masses in the 
vitreous prevent any useful sight. Again, small circummacular dottings 
have been noticed, apparently bearing no relation to albuminuria. Relapses 
are apt to occur. At times the influence of a cerebral tumor producing 
either direct or indirect pressure upon the fourth ventricle may be suspected 
as the causative factor, especially if other localizing symptoms, such as 
ocular paresis and paralysis, be present. 

Prognosis is always bad. Treatment is to be directed towards the systemic 
trouble alone. 

Ocular changes in the insipidus variety of the disease are very much 
rarer than in the mellitus form. The only unequivocal case that the writer 
has had opportunity to study failed to present any coarse ophthalmoscopic 
changes whatever. The patient was a young girl who suffered intensely 
from general symptoms of the disorder. Her mother died of diabetic coma 

1 Outlines of the Practice of Medicine, 1880, p. 366. 

^ Eecueil d'Ophtalmologie, 1887. 

^ See photo-lithograph of Gowers's preparation of capillary aneurism and varicose capil- 
laries from the retina in a case of diabetes with retinal hemorrhages (Medical Ophthal- 
moscopy, 1882, p. 376), from a case under the care of Mackenzie and ISTettleship (Royal 
London Ophthalmic Hospital Eeports, ix. 150). Here, as Gowers says (op. cit., pp. 197, 
198), "the chief change beyond oedema was a peculiar hyaloid degeneration of the intima 
of the arteries and numerous capillarj"- aneurisms." 

* See article by Nettleship and Edmunds in the Transactions of the Ophthalmological 
Society of the United Kingdom, i. 124. 
Vol. IV.— 15 



226 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

following the birth of a child, — a low-grade female imbecile, — who died 
of organic heart-disease eight years later. 

Although acquired syphilis in the young is rather infrequent, yet as the 
early recognition of its symptoms and their treatment are so essential to the 
future welfare of the patient, a brief mention of the various ophthalmoscopic 
signs will be made here. 

In this disease, as in all other dyscrasise, the uveal tract seems extremely 
prone to disturbance. Inflammation of the choroid of either a disseminate 
or a macular variety rapidly involving the retina, and associated with fine 
vitreous opacities, is the most common form ; that this should be so is very 
natural, as the choroid being practically a part of the uveal tract, and rich in 
vascularity, like the iris and the ciliary body, this tunic is very apt to be 
compelled to bear the brunt of the ravages of this dread disease. Should 
the inflammatory changes in the choroid be primary and extend forward 
into the ciliary and iris regions, gummatous swellings, descemetitis, and 
turbidity of the aqueous humor, with the usual pupillary and iritic changes, 
may all manifest themselves. 

Prognosis in all these cases is bad. Treatment should be directed 
towards the dyscrasia ; taking care to prevent the patient from employment 
of the eyes and to keep them at rest by the use of mydriatics and dark 
glasses. 

Diifuse retinitis (probably at times choroidal in nature), showing itself as 
a fine translucent veil-like opacity in the retina, extending far out into the 
retinal periphery, with slight obscuration of the optic disk, is often seen. 
Here the retinal circulation is somewhat disturbed, as shown by venous 
tortuosity and distention, with arterial narrowing at times. Frequently, 
new blood-vessel formation, either with or without the association of whitish 
membranous bauds, extends as irregular loops and net-work forward into 
the vitreous. Sometimes faint, almost invisible opacities can be seen in the 
vitreous humor ; at other times innumerable flocculi float with every move- 
ment of the globe. 

Vision is generally affected, but as a rule, in the minor cases, rapidly 
rises to normal in young and sthenic subjects under judicious alterative treat- 
ment.^ Phosphenes, micropsia, and metamorphopsia have all been noticed. 
Prognosis, especially if the case be seen early and promptly treated, is 
favorable. Relapses, unfortunately, are apt to take place. 

"When the poison attacks the optic-nerve tissue itself, either peripheral 
neuritis appears or simple atrophy takes place. In these cases there is 
generally some cerebral or spinal-cord involvement. Such cases, however, 
are almost unique in children. 

In the congenital type of syphilis, choroidal and retinal changes expres- 

1 At the present time the writer has under his care an eighteen-year old girl, who when 
■first seen, three weeks ago, had a vision of j\, which is rapidly approaching the normal 
under the use of mercurial inunctions. In this case the choroid does not appear to be in- 
vvolved. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDEES. 227 

sive of inflammation as a part of intra-uteriue ocular disturbance may be 
recognized in addition to the other permanent sequelae, such as posterior 
synechia, complicate cataract, etc. 

In the hereditary form of the disease, where the ophthalmic symptoms 
appear in a seemingly healthy organ some time after birth, coarse changes 
in tlie choroid, retina, and optic nerve have all been noted by many ob- 
servers. Irregular atrophic areas bordered by blackish pigment at times ; 
dull, dirty red-gray disks, with diminished calibre of the retinal vessels; 
proliferation of pigment epithelium into the lymph-channels of the vessels 
of the retina, giving pictures closely simulating pigmentary retinitis,^ have 
all been found. 

Retinitis, not only as an extension from choroidal inflammation, as in 
Nettleship's most interesting case,^ in a nine-year-old boy who gave an 
undeniable family history of contagion,^ but also as a probable idiopathic 
disorder, has been recorded. Optic atrophy, without other gross ophthal- 
moscopic change, probably the result of some intracranial lesion or disturb- 
ance of the optic nerve, has also been seen. 

In opposition to Cohnheim's assertion * that he has failed to detect 
tubercles in the choroid in similar conditions of the intestines and lungs, 
the same observer has incontestably shown their presence in miliary tubercu- 
losis ; this latter assertion being substantiated by both Manz ° and Busch.® 
After most careful and painstaking inv^estigation, Lawford'^ has even 
demonstrated the presence of the bacillus tuberculosis in the choroidal 
deposits.^ Wadsworth also reports bacilli in a similar growth which had 
its initial point in the ciliary region. From this it is probable that the 
failure to find them by so many writers is dependent either upon the char- 
acter of the tubercles, the peculiar idiosyncrasy of the jjatieut examined, or 
the fault of the observer. 

Probably the first ophthalmoscopic description of the presence of tuber- 
cles in the choroid was made by Von Jaeger,^ followed by Von Graefe.^^ 

They appear as nodules with whitish summits, gradually fading into a 
yellow tint, and at last assuming the color of the choroid. In size they are 
extremely variable, ranging from less than a millimetre to an area larger 
than that of the disk itself. Their number is very inconstant, ranging, as 



' At the present time the writer is studying such a case at Dr. Wm. F. Norris's clinic 
at "Wills Eye Hospital. In this case the upper incisors are chai-acteristic. 

^ Transactions of the Ophthalmological Society of the United Kingdom, ii. 60. 

^ In this case, ISTettleship says that " the appearances in the left were like those in 
Plate v., rig. 1, of Liebreich's Atlas ; those in the right i-esembled Plate IV., Fig. 1." 

* Archiv fur Ophthalmologie, xiv. 1. 

5 Ibid., ix. 3. 

8 Archiv fiir Pathologische Anatomie, xxxvi. 448. 

' Transactions of the Ophthalmological Society of the United Kingdom, vi. 348. 

^ Transactions of the American Ophthalmological Society, 1883. 

® Oesterreichische Zeitschrift fiir Praktische Heilkunde, January, 1855. 

^fi Archiv fiir Ophthalmologie, xiv. 1. 



228 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

Cohnheim ^ has shown, from a single spot to more than fifty. Large aggre- 
gations are often present. If such massings be large, as in the accom- 
panying monotint, taken from Lawford's case,^ the retina will be markedly 
bulged forward by the overlying retinal vessels, w^hereas the smallest ones 
are invisible upon account of the overlying epithelium. As they grow, 
however, the superimposed tissues degenerate, and thus allow the tuber- 
culous mass to become more and more visible, until at last from a doubtful 
shimmering area the nodule bursts into view as a prominent unpigmented 
spot. As a rule, the macular region is preferred (see the monotint). 

In some instances these fundus-changes may antedate the appearance 
of the general inflammatory symptoms : thus, Fraenkel ^ reports such an 
exception, and Steffen* has seen them six weeks before the outburst of 
a tubercular meningitis. In view of these facts it is positive that were 
intraocular search instituted in all cases of incipient meningeal disease in 
young children, the diagnostician would much more frequently be able, by 
the knowledge of their presence, to determine if this were the true charac- 
ter of the intracranial disturbance. In such instances among children, 
very little is to be expected from subjective symptoms, because vision 
is not necessarily affected, and, when affected, is so only when the ad- 
jacent choroidal and retinal elements begin to suffer. Should the child 
have an acute attack of meningitis, the ophthalmoscopic picture may be 
quite different ; the neuro-retinitis quickly establishes itself, the retinal 
arteries become pressed, the venous channels, as shown in Lawford's case, 
choke, and fine striated hemorrhages may even appear throughout the 
ground. This, however, is by no means a necessary accompaniment, as in 
a case of tubercles of the choroid diagnosed ophthalmoscopically one day 
before the patient's death from acute tuberculosis, ^yells ^ found an almost 
utter want of intraocular disturbance. In this case Vernon ^ demonstrated 
the presence of the tubercles in the choroid by the microscope. Bearing 
in mind Strieker's observation (quoted by Gowers and jSTorris), that they 
may become recognizable in from twelve to twenty-four hours, we should 
not rest content with a single study of the fundus when it is important to 
note their presence. 

Whether it would be wise to follow McHardy's example '^ in enucleating 
an eye containing a rapidly-increasing intraocular growth supposed to be a 
localized tuberculosis of the choroid, in order to prevent general infection, 
it is impossible to say. Both Mules ^ and Eperon^ strongly advocate this 

1 Berliner Klinische Wochenschrift, 1869, No. 4. 

2 Transactions of the Ophthalmological Society of the United Kingdom, 1883, p. 348. 

3 Jahrhuch fiir Kinderheilkunde, Bd., ii. 
*0p. cit., 1870. 

5 A Treatise on the Diseases of the Ej^e, Amer. ed., hy C. S. Bull, 1883. 

® Royal London Ophthalmic Hospital Eeports, ii. 163. 

' Transactions of the Ophthalmological Society of the United Kingdom, viii. 197. 

8 Ophthalmic Review, January, 1885. 

8 Archives d'Ophtalmologie, 1883, p. 485. 



PHOTO. XYI. 




TrBERcrLOSis of the Retina and Choroid. (Lawford, Transactions of the Ophthalmological 
Society of the United Kingdom, 1886.) 



OPHTHALJrOSCOPY : SYMPTOMATIC DISORDERS. 229 

procedure, the latter deeming it lost time to resort to either medicines or 
hygienic measures. At any rate, one must be very careful in attempting 
to decide this most difficult problem, which seems, to the writer's mind 
at least, a question that can be decided only by obtaining a consensus of 
opinion from several authoritative persons in each individual case. 

Of much interest is Mules's instance in a ten-year-old girl.^ 

Very frequently the presence of the gray tubercle has been demonstrated 
in tissues of the retina and the optic nerve. One case is noted by Perls ^ 
in which the uveal tract seemed to be partially implicated. Chiari ^ reports 
an instance where the disk-tissue appeared infiltrated, causing the nerve- 
head to become quite prominent. Both Cruveilhier* and Hjort^ show 
second-nerve deposition as far back as the chiasma. Lawford ^ cites a case 
of a five-year-old boy suffering from tubercular meningitis (see the case in 
greater detail in the section on the Choroid), where, in spite of the optic 
neuritis and the large aggregation of tubercular material in the choroid at 
the situation designated in the monotint, the retina and the optic nerve 
were uninvolved. 

Leprosy. — This dread disease, with its definite bacillus, fortunately is so 
rare in this country that in reality it is known to us as a curiosity only. Its 
eye-symptoms, as a part of the general destructive conditions through which 
the tissues pass, are as multitudinous as the structures of the organ itself. 
Nothing seems to escape ; nerve-substance becomes infiltrated with the 
peculiar cell-form, as shown by Virchow ;^ corneal tissue becomes invaded, 
as exhibited beneath the microscopes of Bull and Hansen ; ^ whilst the 
choroid and even the retina, according to the researches of the same ob- 
servers, do not escape. Although Pollock^ justly tells us that "the disease 
of the eyeball is largely ciliary in origin," yet by continuity of tissue the 
choroid and retina at last become infiltrated, and in some instances total 
loss of sight and even destruction of the globe itself are brought about. 
In most cases, however, the degenerative processes in the anterior segment 
of the organ cause the ordinary sequelae of shrinkage to appear, while in 
some others increased intraocular tension^ with all its evil consequences, 
may ensue. 

Upon account of the early disorganization of the tissues in the anterior 
part of the eye, the ophthalmoscope often fails to give any of the initial 
appearances of infiltration in the choroid and retina. Pollock,^" however, 

1 Medical Times, 1884, ii. 80. 

^ Archiv fur Ophthalmologie, xix. 1. 

3 Wiener. Med. Jahrbiicher, 1877. 

* Anat. Path. Gen., 1862. 

5 Klinische Monatsbliitter fiir Augenheilkunde, 1867, S. 166. 

^ Transactions of the Ophthalmological Society of the United Kingdom, 1886, p. 346. 

^ Krankhaften Geschwulste. 

8 The Leprous Diseases of the Eye, 1873. 

^ Leprosy as a Cause of Blindness, 1889, p. 76. 

10 Op. cit., p. 66. 



230 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

asserts that no atrophic or pigment spots in the choroid have ever been 
observed ophthalmoscopically. Bull and Hansen ^ state that they often saw 
" a light grayish obscuration of the parts of the retina which surround the 
optic disk, with a relative tenuity of the retinal arteries, at post-mortem 
examination." 

LESIONS DEPENDENT UPON TOXICS INTRODUCED INTO THE 

SYSTEM. 

In countries where quinine is used extensively, cases showing the toxic 
effects upon the second nerve have been noted. Thus, Knapp ^ gives an 
account of a female child of seven years, suffering from malaria, in whom 
frequently-repeated euemata of ten-grain doses of the drug caused blindness 
in six days, followed by phosphenes. Upon cessation, central vision gradu- 
ally returned, but peripheral vision remained somewhat impaired. He cites 
two additional cases in boys, aged seven and eight years, where blindness 
soon supervened upon large doses of quinine, the loss of vision only gradu- 
ally and imperfectly returning. E. Williams (loc. cit) reports a similar 
instance after a single ingestion of a large dose, in a fourteen-year-old lad, 
who became totally blind in four days. 

The blindness, which is sudden, is generally associated with a temporary 
deafness with tinnitus, which lasts about a day. The blindness, which is 
much more persistent, gradually lessens until good central and fair periph- 
eric vision are obtained. Curiously, during the convalescence central color 
scotomata are said to appear.^ At first the ophthalmoscope shows a retinal 
condition which closely simulates embolism.* The retinal vessels (both 
arteries and veins) are greatly contracted, and their contents can be removed 
by very slight pressure. Vorhies (quoted by Gowers) ^ asserts that he has 
found the choi'oidal vessels also empty. Gradual, though incomplete, res- 
toration of both form- and color-vision takes place, the first appearing to 
be regained much the sooner. What the rationale may be it is not possible 
to say, though most likely it is dependent upon vaso-motor disturbances, 
giving rise to local changes. We must remember, however, as Norris ^ says, 
that " in many of the reported cases it is difficult to decide positively how 
much of the amaurosis is due to the quinine and how much to the disease 
for which the patient is under treatment ;" he believing that " this is especially 
true where the patient has been suffering from severe intermittent fever or 
from exhausting hemorrhages complicating uterine disease, which are well 
known frequently to produce complete atrophy, with shrinking of the 
vessels." 

1 Op. cit., p. 71. 

^ Archives of Ophthalmology, x. 220. 

* Neul, Traite complet. 

* See Gruening, Archives of Ophthalmology, x. 81, and Brown, Transactions of the 
Ophthalmological Society of the United Kingdom, vii. 199. 

- 5 Medical Ophthalmoscopy, 1882, p. 238. 

* Pepper's System of Medicine, vol. iv. 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 231 

One peculiarity of the disorder as spoken of by Gowers ^ is that, " whilst 
the symptoms are passing off, relapses may be produced by insignificant 
doses of quinine." 

As amblyopia from tobacco, comparatively so common among male 
adults, may at times be found in younger subjects, though of course very 
rarely in children, a brief description of the symptoms will be given. 

From the time of Mackenzie's assertion that most cases of amaurosis 
were caused by tobacco, which was considerably modified by Hutchinson,^ 
to the latest analyses by Browne,^ much has been written for and against it. 
The latest and most important researches by Uhthoff * show that the lesion 
is an axial inflammation with consecutive atrophic changes of the retro- 
bulbar portion of the optic nerve, generally close behind the globe itself. 

In the incipiency of the attack, the optic nerve head appears somewhat 
cedematous and the veins of the retina are apparently tortuous. As the 
case progresses, signs of atrophic degeneration become manifest, the disk 
appears of a peculiar red-gray, with a decided loss of capillarity to the 
temporal side, and the retinal vessels diminish in calibre.^ 

Negative color scotomata, especially for green and red, either centrally 
or somewhat excentrically placed, are found early in the case. Later, they 
become larger, and either unite with the blind spot of Mariotte or extend 
some distance around the fixation-point. Both blue and yellow now rapidly 
disappear, until at last the scotomata become positive in type and cause a 
conscious defect^ in the visual field. At this time the concentric limitation 
of the various fields, which has been progressively increasing, becomes very 
great for botli form and the remnants of color-perception left. 

Prognosis is always good when the case is seen early. Treatment con- 
sists in total abstinence from tobacco. Strychnine and the best of hygiene 
should be employed. 

Alcohol amblyopia is rarely, if ever, seen in children. The ophthalmo- 
scopic signs and the visual symptoms are almost identical with those of 
tobacco. In fact, this is to be expected, since the toxic effects of the drug 
are most probably upon the same strands of optic-nerve fibres. 

Prognosis is favorable. Treatment consists in abstinence from the 
employment of the toxic agent. 

A doubtful case of theine amblyopia is reported to have been seen in 
Russia.'^ 

Salicylic acid, either by itself or in conjunction with some base, is 

1 Medical Ophtlialmoscop3', 1882, p. 239. 

^ Medico-Chirurgical Transactions, 1867. 

^ Liverpool Medico-Chirurgical Journal, January, 1888. 

* Archiv fur Ophthalmologie, 1886, iv., and 1887, 1. 

^ In many cases as seen in adults there are an indescribable tint and appearance of the 
nerve-head which seem almost pathognomonic. 

6 Infrequently, as, for instance, when the study of color-changes constitutes the work 
of the patient, trifling changes in green and red are recognized quite early in the case. 

' Annual of the Universal Medical Sciences, 1888, iii. 126. 



232 OPHTHALMOSCOPY : SYMPTOMATIC DISOEDERS. 

said by Reiss to have given ocular symptoms simulating those of quinine. 
Gatli ^ notes an instance of temporary dimness of vision from a dose of one 
hundred and twenty grains of salicylate of sodium. The patient, a sixteen- 
year-old girl, was suffering from an acute attack of articular rheumatism. 
The fuudus-oculi changes were limited to undue fulness of the retinal veins. 
Both pupils were dilated. Schiffer ^ gives an account of hallucinations of 
vision, lasting one day, following an enema of seventy-five grains of the 
same drug. 

It frequently occurs, and in fact constitutes one of the physiological 
proofs of the assimilation of the drug, that santonin, given ordinarily as a 
vermifuge in children, produces xanthopsia, which lasts several hours. Of 
some importance, however, are the results upon the fundus oculi which 
are occasioned by much larger doses of the drug. In such instances, 
subnormal color-perception, associated with marked diminution of central 
vision, is more profound and lasting. 

Mittendorf ^ reports an instance of visual impairment, with central scoto- 
mata for green and red, in an adult patient who had been taking from 
forty to sixty grains of chloral hydrate daily for six months. The nerve- 
head appeared " muddy." Upon the patient's ceasing to use the drug, and 
after the administration of strychnine, vision rapidly improved and the 
scotomata disappeared. 

Noyes * mentions that " great and sudden amblyopia" has been caused 
by osmic aeid. 

Mytiloioxine, the poisonous ptomaine said to originate in diseased mus- 
sels (with physiological effects strongly resembling those of curare), is said 
by Dutertre ^ to produce visual troubles. 

A very curious instance of blue discoloration of the eye-grounds has 
been seen by Litten ® in a patient poisoned by nitro-benzol containing ani- 
line. In this case the entire surface of the body was similarly discolored. 

The toxic action of lead, like that of many of the other poisonous 
agents, produces either temporary blindness without any visible flindus- 
lesion, optic neuritis, or simple atrophy. The first, which is generally 
both sudden and extremely transient, fails to show any distinctive oph- 
thalmoscopic signs. The second, which is quite pronounced on both 
sides as a rule, with numerous feathery hemorrhages from both con- 
tracted arteries and distended veins, is frequently recurrent in its inten- 
sity. At times there may be almost total annihilation of sight, lasting for 
a day or two. These losses of vision appear to have no relation to any 
visible changes in the fundus oculi, and seem to be associated with 

1 Gazzetta degli Ospitali, Milan, 1880. 

'■^ Archives Mensuelles de Medecine et Chirurgie, 1887. 

'^ Ophthalmic Eeview, October, 1888. 

* A Text-Book on Diseases of the Eye, 1890, p. 634. 

^ EecvTeil d'Ophtalmologie, 1887. 

•" Centralblatt fiir Praktische Augenheilkunde, April, 1881. 



OPHTHALMOSCOPY : SYMPTOMATIC DISOEDERS. 233 

the first form of visual disturbance. Waclsworth^ reports a very in- 
teresting case of double optic neuritis with ophthalmoplegia from lead- 
poisoning (complicated by typhoid fever) in a nine-year-old boy. Hutchin- 
son ^ reports several instances of optic neuritis which were followed by 
atrophy. The third form, which may be either simple or consecutive, is 
manifested by a gradual decrease of the capillarity of the head of the 
nerve, with lessening of the retinal- vessel calibre, until sight is absolutely 
lost. Wells ^ gives the notes of a case of complete blindness from the 
consecutive type in a young woman, a worker in lead. The writer has 
at present a most interesting case of this type in an adult, who is fast be- 
coming blind. Careful analysis of definite volumes of the urine, the saliva, 
the nasal mucus, and the tears, by Dr. John Marshall, revealed the presence 
of certain percentages of lead in every excretion but the last. The descrip- 
tion of the fundus-changes and the transient peculiarities of the fields of 
vision in this c^se will be reserved for future publication. 

In all the cases, cephalopathic symptoms are so frequently apparently 
visible that the utmost caution must be exercised before any absolute diag- 
nosis is given. In fact, the presence of lead in the tissues and excreta, and 
the other pathognomonic symptoms of saturnine intoxication, such as wrist- 
drop, colic, etc., are the only certain evidences of the causative factor. 

In many cases of prolonged poisoning, the renal apparatus is made to 
suffer to such a degree that both albumen and tube-casts can be readily 
detected in the urine. From this fact the query arises, Does lead-absorp- 
tion mean endarteritis, with all its dire consequences, just as is found so 
frequently to be the case in so-called Bright's disease ? 

In both the neuritic and the atrophic form the prognosis is very bad. 
The amblyopic variety can be frequently bettered by the use of iodide of 
potassium. 

The symptoms of the action of volatilized mercury upon the nervous 
system are well knoAvu. As a part of these, both optic neuritis* and 
atrophy ^ have been observed. The doubtful influence of acute hydrargyria 
upon the kidneys must be borne in mind in these cases. 

True argyria, independently of the beautiful pictures of conjunctival 
staining as shown by Grossman ^ to have been produced by topical applica- 
tions of strong solutions of nitrate of silver, has been found by R.eimer'' to 
have existed in the sclerotic sheath of the optic nerve. GoAvers ^ states that 
"silver-poisoning is said to be accompanied by amblyopia in addition to the 



^ Transactions of the American Ophthalmological Society, 1885, p. 54. 
2 Royal London Ophthalmic Hospital Reports, vi. 1, and vii. 1. 

* A Treatise on the Diseases of the Eye, 1883 (American edition), p. 600. 

* Galezowski, Des Amblyopies et Amauroses toxiques. 
5 Gatli, Gazzetta degli Ospitali, Milan, 1880. 

^ Ophthalmic Review, June, 1888. 

' Quoted in Gowers's Medical Ophthalmoscopy, 1882, p. 239. 

8 Op. cit,,p. 239. 



234 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

Other symptoms of argyria." Again, it must be remembered that kidnev- 
affections and vascular disease, which are so prevalent in certain forms of 
chronic metallic poisoning, may play important parts in the production of 
visual disturbance and optic-nerve inflammation. 

Arsenical poisoning, like lead-poisoning, is apt to give rise to marked 
nervous symptoms. As with mercury, the usual mode of entrance of arsenic 
into the system is by inhalation. Dana, however,^ reports a case of optic 
neuritis with other nervous groupings following an acute poisoning by the 
drug. Seguin,^ in speaking of chorea and its treatment by arsenic, says 
that he has never seen symptoms of multiple neuritis or of optic neuritis 
from the medicinal use of arsenic. 

In addition to the ordinary toxic effects of the constant inhalation of 
the vapor of bisulphide of carbon and chloride of sulphur, ophthalmic symp- 
toms have been noted. Xettleship^ cites an instance of a young maa of 
twenty vears who had been employed in an india-rubber works for ten 
months, whose vision had failed to ^, with a central defect for red. The 
visual fields were said to be normal, whilst the optic disks were pale and 
slightly hazy, these symptoms being partly relieved by discontinuance of 
work. Huguenin * gives two cases, the first in a fifteen -year-old boy, who, 
after four months' exposure, had failure of vision and was unable to recog- 
nize green, Xine months later vision was bettered. The second case, a 
girl who had been exposed for two years, had "chromopsia" (red and 
green), with failure of sight. Becker ^ notes a most instructive instance. 

In nearly every instance the patient gazes as it were through a fog, 
this symptom becoming more pronounced when the patient is tired or fast- 
ing. Central scotomata have been found, whilst the optic nerve itself 
frequently shows signs of a low grade of chronic inflammation. Prognosis 
is, as a rule, good. Treatment consists in the avoidance of the fumes of 
the drugs, together with the use of both local and general hygiene. During 
the attack, Nettleship employed strychnine in his case, seemingly to advan- 
tao:e, after havino; unsuccessfully tried "the constant current." Lavigerie^ 
claims good results from the use of strychnine and iodide of potassium. 

UNCLASSIFIED. 

As shown by Leber,^ retinitis pigmentosa is a chronic disturbance, which 
consists in proliferation of connective material associated with degeneration 
of nerve-tissue and wandering of pigment-massings into the substance of 
the retina. From this last objective condition of the disorder, which in 
reality is sometimes wanting (?), the disease receives its name. 

1 Brain, ix. 456. ' ^ New York Medical .lournal, April 5, 1890. 

3 Transactions of the Ophthalmological Society of the United Kingdom, v. 149. 

* These de Paris, 1874. 

= Centralblatt fiir Praktische Augenheilkunde, May, 1889. 

fi Jour, de Medecine et Chirurgie, 1887. 

7 Graefe und Saemisch, Handbuch der Gesammten Augenheilkunde, Band v- 



PHOTO. XVII. 




Retinitis Pigmentosa. (Jaeger, Beitriige zur Pathologie des Anges, Plate XXXVII.) 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 235 

These conditions, which are more extensive in the peripheral portions 
of the retina, gradually advance towards the region of the yellow spot. 
Atrophic degeneration of the optic nerve extending outwardly soon shows 
itself ophthalmoscopically, whilst the degeneration areas even pass inwardly 
beyond the point of intracranial crossing. 

Ophthalmoscopically, the fundus-oculi changes are very apparent. As 
shown in the accompanying monotint, taken from Jaeger's Atlas, the pig- 
mentary deposit lies far out in the periphery of the ground and stands 
comparatively well forward in the retinal layers, — the massings, as a rule, 
having a much less decided preference for the temporal side of the ground. 
The pigmentation itself, as can be readily seen, assumes a distinctly bone- 
corpuscle-like appearance. Ofttimes these massings seem to follow the 
course of the main retinal stems. Throughout the eye-ground, though less 
pronounced in the macular region, there is marked absorption of the pig- 
ment epithelium, which allows the larger underlying choroidal vessels to be 
plainly visible. At times the retina itself between the pigment-aggrega- 
tions appears as a grayish film. Both series of retinal vessels are small, 
with thickening and opacification of their walls.^ Curiously, the tissues in 
the macular region seem to remain intact for a long time.^ The nerve-head, 
which at- first is reddish gray in tint, becomes more and more gray, until at 
last it assumes a dull-white appearance. 

In the early stages of the disease, an increasing inability to see properly 
in dim light manifests itself, this incompetency of vision frequently show- 
ing itself by the patient's stumbling over large objects situated in unaccus- 
tomed places. Again, the patient will assert that there is a gradual lessen- 
ing of the area of vision. As the case grows worse, both peripheral and 
central vision fade, until at last absolute (or almost complete) blindness 
ensues.^ Fortunately, in some cases the condition remains stationary after 
reaching a certain point. 

The disease is said at times to be congenital, or it may appear early 
in life. Tliere can be little doubt that it is distinctly hereditary. The 
writer has notes of six cases in four generations, the order of sequence 
being from an affected mother to three affected grandsons and one affected 
grand-daughter by an unaffected father; another (the first) daughter 
(unaffected) of this father having one boy and one girl, — the boy being 
affected. Consanguinity existed in this grouping. 

Prognosis as to betterment of sight is always bad. Although treatment 
has been found of little or of no value, yet Hasket Derby's and Myles 

' The sketch does not show this. 

2 Even in the earliest stage this is not strictly true, because if careful testing for central 
color-perception be made at that time, evidences of slight green and red subnormal percep- 
tion can be determined in most instances. In contradistinction to this, however, hyperaes- 
thesia has been asserted in a few cases, — possibly from primary abnormal excitation through 
slight exacerbations of chronic low-grade inflammatory changes. 

3 At times these clinical groupings may be interfered with, giving rise to all manner of 
anomalous symptoms. 



236 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

Standish's suggestions^ for the use of electricity should be conscientiously 
tried in every instance. Alteratives in association with the best hygienic 
measures must always be employed. 

The works of the older writers teem with imperfect histories of cases 
of so-called hemeralopia. Wonderful, however, is the accuracy with 
which intraocular conditions were guessed at without the use of the oph- 
thalmoscope, and most interesting are the accounts of sailors, soldiers, 
workers before bright glares, travellers under the tropic sun and through 
the arctic snows, who are supposed to have been subjects of the disease. 

The conditions sometimes appear connected with scurvy, interference 
with the functions of the liver, starvation, etc. Forry^ thinks that it is 
rare in the United States, and that it is much more prevalent in the Southern 
States than in the Northern. 

In the great majority of cases ophthalmoscopic signs are wanting, 
though Wells^ has seen a slight dilatation of the retinal veins. The pupils 
are said to be dilated, and the irides are generally noted as sluggish to light- 
stimulus. 

The patients declare an inability to recognize objects by feeble illu- 
mination. At times both peripheral vision and central color-perception 
seem to be below normal.* Both negative and positive scotomata have been 
found in the visual fields. Phosphenes and subjective after-colors have 
been noted. Both eyes are affected. 

The disease appears suddenly. Prognosis is good. Treatment consists 
in tonics, taking care to give the patients the best of hygiene and to place 
them under the influence of subdued light, as, for instance, in cool, comfort- 
able, darkened chambers, or, better, to protect their eyes by smoked glasses. 

Nettleship^ notes the case of a patient with " stationary night-blindness 
with minute white spots at the fundus." In this case the fundus oculi 
seemed to be studded with small non-pigmented v/hite dots, these being less 
pronounced in the macular region. The patient, aged twenty-one years, 
complained that he had had difficulty in seeing in the dark for as long a 
time as he could remember. Gayet^ has described two similar instances 
under the supposititious title of " Retinitis Pigmentosa." 

On account of the elasticity of the ocular tissues and the freedom of 
fluid interchange, glaucoma in childhood is very rare. Most of the few 
instances recorded show either progressive myopia with stretched ocular 
walls, or incarceration of inflammatory material in situations where con- 
stant secretion and excretion are taking place. 

^Transactions of the American Ophthalmological Society, 1887, pp. 555, 556. 
2 American Journal of the Medical Sciences, April, 1842. 
^ A Treatise on the Diseases of the Eye, 1883 (American edition), p. 606. 
* Foerster (Ueber Hemeralopie, 1857) has found that blue, violet, and red are the colors 
that are the most difficult to recognize by these cases. 

^ Transactions of the Ophthalmological Society of the United Kingdom, 1888, p. 163. 
6 Archives d'Ophtalmologie, 1883, p. 386. 



PHOTO. XVIII. 




Glaucomatous Excavation. (Jaeger, Beitrage zur Pathologie des Auges, Plate XVIII.) 



OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 237 

The writer has seen two instances, one of the secondary type and the 
other of uncertain origin, at Dr. Wm. F. Norris's out-patient service de- 
partment at Wills Eye Hospital. Both patients were boys, one aged eleven 
and the other thirteen years. In the younger child the changes in the ante- 
rior portion of the globe were so pronounced ^ that it was very difficult to 
study accurately the pathological excavation in the nerve-head. Tension 
was increased. 

In the second case, without any history of accident, the sight of the 
right eye was said to have been "always poor." Here also intraocular 
tension was increased (+ T 1). The field of vision was markedly con- 
tracted to the nasal side : the pupil was larger than that of the lefi: eye, 
and the iris was somewhat sluggish to light-stimulus. Vision with this 
eye equalled one-ninth, which was increased to one-sixth by a correction 
for a low amount of mixed astigmatism. A shallow - though well-marked 
glaucomatous excavation, more pronounced to the temporal side of the disk, 
could be plainly seen with the ophthalmoscope. No marks of traumatism 
or of opacity were discernible. The fellow-eye had a vision of one-half, 
which was bettered by a weak convex cylinder. The visual field was con- 
tracted in the same way as that of the opposite eye, but not to the same 
extent. Accommodation was fair, though, as in the other eye, it plainly 
indicated spasm. No glaucoma cup could be determined positively. The 
intraocular tension was apparently normal. The better eye was the fixing 
organ, the fellow-eye wandering out during the act.^ 

Many of the cases of ciliary and corneal staphylomata and buphthalmos 
seen in the young are mere expressions of what would be glaucoma in older 
subjects under similar circumstances. 

The ophthalmoscopic picture of glaucoma, which is so well represented 
by the accompanying reproduction of one of Jaeger's plates, is typical of in- 
creased intraocular tension. The soft substance of the nerve-head is pushed 
backward against itself, exposing the sclerotic ring with its sharply-cut 
edge, against which the retinal vessels are forced. In the bottom of the 
pathological excavation the flattened veins can be dimly seen with the lens 
that renders the scleral edge of the nerve plainly visible. By gradually 
weakening the focussing power of the ophthalmoscopic lenses, the details of 
the bottom of the pit can at last be brought into distinct view. Upon ac- 
count of the increase of the intraocular tension giving greater obstruction 
to the arterial current as it enters the globe, the arteries appear small, whilst 
the corresponding veins, for the same reason, seem wider and more flattened. 

Often the excavation is only partial ; in such cases, as a rule, it is to the 
temporal side of the disk. Again, an original physiological cupping with 

^ Anterior leucoma with ring-like opacities in the lens, the sequelae of a traumatism 
when the patient was six or seven years of age. 

^ One diopter. 

^ Careful examination showed that this was dependent upon insufficiency of the 
interni. 



238 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

an underlying or a circumscribing pathological excavation may give a ter- 
raced appearance to the depression. Spontaneous venous pulsation is often 
present, and an arterial pulse may be easily obtained by pressure with the 
finger upon the eyeball. 

The visual field is frequently characteristic, the contraction, as a rule, 
first appearing to the nasal side.^ Visual acuity is usually very faulty. 

Prognosis is certainly bad, and treatment to be of any value must con- 
sist in iridectomy. This, however, should not be done without the advice 
of some competent authority and without giving the patient's friends a 
clear understanding of both the immediate and the remote dangers of the 
operation. 

In countries such as North Germany, where various preparations of 
raw pork are eaten, the parasite cysticercus cellulosse has been found between 
the retina and the choroid. When in this position the retina rapidly be- 
comes detached and the overlying tissues grow opaque and turbid, whilst 
surrounding inflammatory change and atrophic degeneration soon take 
place. In all such cases, even before any gross local changes have ap- 
peared, the presence of the parasite cannot be determined with any degree of 
accuracy, although Stellwag^ says, "In some rare cases the head and neck 
are rarely seen through the opacity as a movable, deeply-clouded mass." 
Ofttimes the entozoon becomes encapsulated. Becker,^ Schweigger,* Jacob- 
son,^ and Devencentiis® have all seen such cases. 

Prognosis is always bad, even though a considerable number of suc- 
cessful attempts at extraction of the parasite have been made by Alfred 
Graefe and others. 

As gross congenital subnormal color-perception {color-blindness) exists 
among us in so great a degree, a few words are necessary for its study 
and recognition. The colors most frequently confounded are green and red ; 
for instance, a red berry is not so distinctly separated from the green leaves 
by its color-difference as it is by the comparative intensities or strengths of 
the colors themselves and the differences of form of the two objects. The 
proper color-designation may be given in each case, but should color-com- 
parison be attempted, as, for instance, with a number of red and green 
berries of the same intensity of color, or a quantity of red and green leaves 
of similar intensities, both the berries and the leaves would be hopelessly 
confounded, since here, in each case, color-perception alone is called into play. 

Many accurate accounts both of historic and of scientific interest could 
be given, as, for instance, Huddart's case^ of the shoemaker Harris, Avho 

1 This test cannot always be depended upon, as there are exceptions. 

'■^ A Treatise on the Diseases of the Eye, 1868, p. 474. 

^ Zeitschrift der Wiener Aerzte, 1865. 

* Archiv fur Ophthalmologie, vii. 2, 53. 

s Ibid., xi. 2, 148. 

^ Annali di Ottalmologia, vol. xvii., No. 1. 

' Philosophical Transactions, London, 1777, Ixvii. 260. 



OPHTHAT.]\rOSCOPY : SYMPTOMATIC DISORDERS. 239 

when a child could distinguish ripe cherries from green leaves in no other 
way than by their difference in size and shape, and Nicholl's case^ of a 
boy who was found to possess subnormal color-perception for both green 
and red. 

As examination of the color-sense has not been made a routine meas- 
ure in any of our public or private educational institutions, the com- 
plaint is most frequently brought to our notice by the subject himself. 
Examination by some one of the plans of loose-wool selection, if conscien- 
tiously done, will soon reveal the defect. Treatment is of no avail ; but 
careful training among colors and shades should be given to all young 
persons who are known to have such a defect, in order that a compensa- 
tory power, in an ability to recognize color-differentiations by the finer and 
more delicate choices of shades and intensities, especially in employments 
which require such discrimination, as, for instance, photographing, engrav- 
ing, etching, etc., may be imparted to them, — a training that will render 
them better able to perform such work than those who possess ordinary 
color-perception. 

It will be remembered that whilst speaking of hysteria and its blind- 
ness the unintentional type was noted as of frequent occurrence. Here, 
however, pure malingering, or conscious simulated blindness, which is more 
difficult to detect, will be briefly considered. Odd as it may appear, 
scholars desirous of escaping routine school-work, and children Avith a 
wish for sympathy or condonement, have calmly but strenuously per^ 
sisted in the assertion of either complete or partial blindness, without any 
detection by ordinary means at hand. If the child be old enough, various 
procedures with prisms which produce double and erroneous projections of 
objects, or convex lenses and mydriatics which either so alter the focussing 
power of the two eyes as to render binocular fixation impossible, or ex- 
clude the avowedly good eye from action, should be made by some com- 
petent person. Artificial anesthesia may also be tried, so that an attractive 
object may be offered to the supposed malingerer before he has sufficient 
command of his intellect to continue the fraud. 

As it may be not only of interest, bat possibly of medico-legal value, 
to have additional means of recognizing the certainty of general dissolution 
in the young beyond the persistence of muscular excitability to electric 
stimuli and the failure of the ordinary signs of decomposition, it has been 
thought fit to insert a few words giving some of the most important oph- 
thalmoscopic changes which can he seen in such cases. Should careful 
study be made, the retinal arteries will be found to decrease steadily in 
size during each successive weaker impulse of the heart ; the disk-capil- 
laries will rapidly disappear ; the substance of the nerve-head appears 
more and more blanched ; the choroid pales ; the blood in the retinal 
veins breaks into beaded currents and disappears ; and, lastly, the retina 

1 Medico-Chirurgical Transactions, 1818. 



240 OPHTHALMOSCOPY : SYMPTOMATIC DISORDERS. 

becomes rapidly opaque. This last chauge, which may be made more 
noticeable for several hom^s after death by constantly moistening the surface 
of the cornea, is unequivocal in its significance. At this point, however, 
the media become so opaque that further examination of the fundus is 
impossible. 

Gayet^ has been so fortunate as to notice a red spot at the macula lutea 
of the same character as that which can be seen in cases of embolus of the 
central artery of the retina, — this condition, no doubt, being dependent 
upon the increasing haze of the retina permitting the reddish-yellow reflex 
of the underlying choroid to be last seen at the thinnest portion of the 
sentient membrane, the fovea centralis. Kyerson,^ who was enabled to 
study the fundus-changes in the eye of an injured man who was dying, 
gives a most interesting account of the ophthalmoscopic details. In this 
instance it is noted that there was occasional venous pulsation. Careful 
studies have also been made by Bouchut,^ Poncet,'' Schreiber,® Arlidge,^ and 
others. 

1 Annales d'Oculistique, 1875, Ixxiii. 1. 
'^ Canada Lancet, April, 1888. 

2 Traite des Signes de la Mort, 1863. 

* Archives Generales de Medecine, 1870, 6, xv. 408. 

5 Deutsches Archiv fiir Klinische Mediciu, xxi. 100. 

6 West Eiding Asylum Keports, 1871, i. 73. 



PART III. 

HYGIENE, 

PHYSICAL DEVELOPMENT. 

By J. M. KEATING, M.D., 

AND 

J. K. YOUNG, M.D. 



In considering the snbject of physical development in children, the 
normal development of the cliild, the physical type of man, increased 
physical development, and the influence of physical development in the 
treatment of deformity and disease, will all be included. 

M. Laiue, Darwin, Chaill6, and others have investigated the dawn and 
development of the intellectual faculties ; Eussow, Hahner, Zeising, Stephen- 
son, and others have observed the general increase in stature and weight ; 
the physiology of infancy has been dealt with elsewhere. There remains 
the normal physical development through the succeeding periods of infancy, 
childhood, and youth. 

" If we are to devote our attention, before all things, to what can be 
measured and weighed, the living man is the first object which demands 
our investigation." (Carl Vogt.) 

MEASUEEMENT OF THE HUMAN BODY. 

This leads naturally to the consideration of the ])hysical proportions of 
the body, of the measurement and strength of different individuals, or of 
those of the same individual at different periods of life. This investiga- 
tion, or the study of anthropometry, does not at this early period assume the 
importance which it has in adult life. Later, the political asi)ect of the 
subject, bearing on the recruiting for the army and navy, the scientific 
Vol. IY.— 16 241 



242 PHYSICAL, DEVELOPMENT. 

importance of the effect of climate, seasons, and peculiar hygienic con- 
ditions, and the classification of the various races of mankind, are to be 
considered. It is, however, of distinct social importance in ascertaining the 
proportions most favorable to health, longevity, and physical endurance, 
in the diagnosis of diseases, accidents, and deformities, and in the insurance 
of lives and the fitness for certain duties. 

Naturalists have concluded that the best means of classifying the races 
and varieties of mankind are measurements of the different dimensions of 
the body, and, in a more restricted view of individual interest, measure- 
ment constitutes the best means of ascertaining the changes occurring in 
the conformation of the body under the influence of age, sex, nurture, occu- 
pation, sanitary conditions, and the general effects of physical culture and 
athletic sports upon the economy. 

Anthropometry has at the present day a voluminous literature of its 
own.^ Its entire history is an attempt to establish a standard by which to 
determine and compare the proportions of the human body. From pre- 
historic antiquity the hand, foot, and cubit (forearm) have been convenient 
standards, possessed by every one and of sufiicieut accuracy to enable man 
to adjust his dealings with his fellow-man and construct his places of resi- 
dence or of worship. These rude standards served for ages, and are still 
retained by civilized nations, notwithstanding the precise standard which 
they now possess through the perseverance and skill of the French mathe- 
maticians. 

The early attempts made to ascertain the average foot and average cubit 
for the purposes of trade led to series of measurements, which, being ad- 
mitted as standards, naturally induced artists and sculptors, in the earliest 
days of art, to endeavor to deduce the exact proportions of the perfect 
human form. 

In the "Silpi Sastri," or Treatise on the Fine Arts, the earliest known 
Sanscrit manuscript, the human figure is divided into four hundred and 
eighty parts, the head being nearly a seventh part, conforming to the best 
standards of the present day : 



PEOPOKTIONS OF THE HUMAN BODY, FPvOM THE "SILPI SASTRI." 

From the umbilicus to the pubes 53 parts. 

From the pubes to the knee . . 90 " 

The knee itself 30 " 

The leo- and foot 102 " 



The hair 15 parts 

The face 55 " 

The neck 25 " 

The chest 55 " 

From the chest to the umbilicus .55 " 



Entire height 480 parts. 



It is highly probable that the Egyptians early possessed a standard 
of proportion, for Rosellini and Lepsius, after a careful examination of the 

1 See for complete bibliography Dr. J. H. Baxter's Statistics, Medical and Anthropo- 
logical, of the Provost-Marshal-General's Bureau of the United States, vol. i., and Roberts's 
Manual of Anthropometry. 



PHYSICAL DEVELOPMEXT. 243 

figures found upon Egyptian monuments, showed that the artists conformed 
rigorously to a definite scale of proportions, and Lepsius has deduced three 
canons of measure in use at different periods. 

While one naturally turns to the matchless works of the Greek artists 
for examples of perfect symmetry, it is to be regretted that no writings of 
Greek authors treating especially ujDon the proportions of the human body 
have been preserved. It is known that at a very early period a system, 
rigorously minute in detail, had been introduced from Egypt, for Diodorus 
Siculus informs us of the construction of the Pythian Apollo, the two halves 
of which were executed by two sculptors in different cities, one being at 
Samos and the other at Ephesus. So exact were the details of the svstem 
that upon uniting the separate portions the statue proved to be a marvel 
of perfection and symmetry. 

The statue of the celebrated sculptor Polykleitus known as "The 
Canon," but called also, from the subject, Doryphoros, or "The Spear- 
Bearer," was constructed upon an admirable theory of proportion, and was 
believed by the sculptor and his pupils and admirers to be absolutely 
perfect in form. Its effect upon Greek and Roman waitings w^as marvel- 
lous and long-continued, although neither the statue nor a copy of the 
treatise describing it remains. 

Vitruvius, the Roman writer on architecture, has incidentally given a 
partial account of proportions which were long considered authoritative. 
He writes : 

" The human body, as nature composed it, has this proportion, that the 
face, Avhich includes the space from the chin to the top of the forehead, 
where the roots of the hair begin, is a tenth part of the whole height ; it is 
the same length from the wrist to the tip of the middle finger. The head, 
from the chin to the top of the skull, is one-eighth part ; the same to the 
pit of the neck. From the toj) of the chest to the roots of the hair is 
one-sixth part, and to the top of the head one-fourth. The third part of 
the face is from the bottom of the chin to the lowest part of the nostrils ; 
one-third from there to between the eyebrows ; one-third from this latter 
to the roots of the hair, where it begins on the forehead. The foot is 
one-sixth part of the whole height, the cubit one-fourth, the chest (across the 
shoulders ?) the same. 

"The other members have each their measures and proportions, by 
which the greatest of the ancient painters and sculptors who have won 
signal honors have guided themselves. In the same Avay the parts and body 
of a temple have definite laws of proportion. 

" So, too, the navel is naturally the centre of the body ; for, if a man 
be laid upon his back, with hands and feet extended, and his navel be 
taken for the centre, the circumference of a circle so drawn would touch 
the extremities of his fingers and toes. 

" Not only is the scheme of the circle found in the body, but also the 
scheme of the square ; for, if the distance from the soles of the feet be 



244 PHYSICAL DEVELOPMENT. 

taken to the summit of the head, and be applied to the hands outstretched, 
it will be found that the length and breadth are equal as a perfect 
square." 

Though serving as the groundwork for subsequent works, many of 
these measurements are undoubtedly incorrect ; notably, the position of the 
umbilicus as the centre of height in the adult, and the distance from the 
top of the sternum to the summit of the cranium. 

The statement that the perfection of Greek statuary was due to the 
superiority of the living models from whom they were designed receives in 
the exact statistical data of man-measurements in our day a more decided 
denial than sesthetic criticism could ever have produced. 

We have the authority of M. Quetelet for the statement that the 
physique of man to-day compares favorably with that during the time 
of the early Greeks. After a careful comparison of the dimensions of the 
best masterpieces of antiquity with the average results of modern statistical 
research upon the living, he declares, " It is, then, wrong to suppose that 
man in our clime differs essentially from the structure observed in the 
Greek statues. The delicacy and beauty of feature, the expressiveness of 
countenance, the elegance of form, may be inferior without the proportions 
of figure being different on that account. Everything tends to establish, 
on the contrary, that the human type in our clime is identical with that 
deduced from observation of the most symmetrical ancient statues." 

The early authors employed but few models to determine the size and 
conformation of the parts, but took infinite precautions to unite exactitude 
of form with elegance of proportion. Phidias employed twenty models, it 
is said, to arrive at elegance, selecting from each the most beautiful parts, 
and arrauffino; them according to his kuowledsre of the human form. 

During the era of the Renaissance the canon of Polykleitus retained its 
influence, as is shown by the artificial nature of all the systems propounded. 
A part of the body, the cubit, hand, foot, head, face, or nose, M^as selected 
as the unit or basis of calculation, and every other part had a forced rela- 
tion thereto.^ 

The character and limits of this sketch will not permit more than an 
allusion to the artists, sculptors, anatomists, mathematicians, and others 
who since the Renaissance have contributed theories or treatises upon the 
proportions of the human body, but a short description of the models and 



1 " The standards of the proportions of the body employed by ancient and Renaissance 
sculptors and artists were taken from different parts of the body ; and, although they are 
not of much value to science, they are full of interest to those who appreciate their incom- 
parable worlds of art. They were the cubit of the Egyptians, or the distance between the 
elbow and the extremitj' of the fingers ; it forms the fourth part of the height of man. 
The foot, which forms the sixth part. The head, which, according to Vitruvius, forms the 
eighth part ; but, properly speaking, the head is contained seven and a half times in the 
height. The face (volto), which is equal to the length of the hand, and is the ninth part 
of the total height." (Eoberts, loc. cit.) 



PHYSICAL DEVELOPMENT. 245 

treatises of Alberti, Albrecht Diirer, Reynolds, Cams, Story, and Quetelet 
will serve to illustrate the progress of the subject to the present day. 

Alberti may be said to have followed the canon of Vitruvius in taking 
the foot to be one-sixth of the entire height, and thus rendered his scheme 
defective. The adoption by him of the average or mean and of a decimal 
system of division is, however, noteworthy. 

The peculiar feature of the measurements of Diirer is that they repre- 
sent three points of view, — profile, front, and back ; and Schadow, the 
author of the " Polyclet," expresses the opinion that his model figure was 
the result of calculation, and not of actual measurements of living subjects. 

Science owes to Sir Joshua Reynolds the idea of the existence of a 
typical form in man, and the order which prevails in the apparent varia- 
tions from that type. " All the objects," says he, " which are exhibited 
to our view by Nature, upon close examination will be found to have their 
blemishes and defects. It must be an eye long used to the comparison 
of these forms, and which, by a long habit of observing what any set of 
objects of the same kind have in common, has acquired the power of dis- 
cerning what each wants in particular. By this means we acquire a just 
idea of beautiful forms ; we correct Nature by herself, her imperfect state 
by her more perfect, and make out an abstract idea of forms more perfect 
than any one original. . . . From reiterated experience and a close com- 
parison of the objects of Nature, the artist becomes possessed of a central 
form from which every deviation is deformity. ... To the principle I 
have laid down, that the idea of beauty in each species of being is an 
invariable one, it may be objected that in every particular species there 
are various central forms, which are separate and distinct from each other, 
and yet are undoubtedly beautiful ; that in the human figure, for instance, 
the beauty of Hercules is one, of the Gladiator another, of Apollo another, 
which makes so many different ideas of beauty. It is true, indeed, that 
these figures are each perfect in their kind ; but still none of them is the 
representation of an individual, but of a class. And as there is one gen- 
eral form which belongs to the human kind at large, so in each of these 
classes there is one common idea and central form which is the abstract 
of the various individual forms belonging to that class. Tlius, though the 
forms of childhood and age differ exceedingly, there is a common form in 
childhood and a common form in age, which is more perfect as it is more 
remote from peculiarities. But I must add further, that, though the most 
perfect forms of each of the general divisions of the human figure are ideal, 
and superior to any individual form of that class, yet the highest perfection 
of the human figure is not to be found in any one of them. It is not in 
Hercules, nor in the Gladiator, nor in the Apollo ; but in that form which 
is taken from them all, and which partakes equally of the activity of the 
Gladiator, of the delicacy of the Apollo, and of the muscular strength of 
the Hercules. . . . There is, likewise, a kind of symmetry or proportion 
which may properly be said to belong to deformity. A figure lean or 



246 PHYSICAL DEVELOPMENT. 

corpulent, tall or short, though deviating from the type, may still have a 
certain union of the various parts which may contribute to make them on 
the whole not unpleasiug." 

It remained, however, for M. Quetelet to reduce this artistic conception 
to a scientific basis, and demonstrate its soundness and usefulness by exten- 
sive and painstaking observation on living models. 

Before considering the methods of M. Quetelet, which, being based on 
the inductive, strongly recommend themselves to every student, we must 
consider the work of Prof. Cams, a distinguished physiologist of Dresden, 
w^hich is based on the deductive method of investigation. 

He assumed the hand's length for his unit, dividing it into twenty-four 
parts, and considered the true key to our proportions to be the vertebral 
column, consisting of twenty-four free vertebrae, — " the true organic ell, 
divided into twenty-four inches." He confirmed his view by observing that 
in the egg of mammals the first indication of the future animal was a rayed 
line which subsequently becomes the spinal column, and also by observing 
that a ratio of length exists in the vertebral column of the new-born infant 
and the adult, the length of the former being exactly one-third the length 
of a line drawn perpendicularly from the spinous process of the atlas to the 
spinous process of the last lumbar vertebra in the adult. This standard, 
or " modulus" of a third of the length of the adult spine, furnishes, when 
divided by the authoritative measure of twenty-four, all the dimensions 
required to deduce the perfect form. Upon this he constructed a figure, a 
sexless statue, but one capable by a slight variation of being modified to 
represent either sex, and capable also, by the application of certain rules, of 
representing a dwarf or a giant, a poet, a philosopher, or an athlete. The 
" modulus" may, indeed, be theoretically correct, but for scientific purposes 
it renders no assistance to the knowledge of the progressive development 
of the body, as the different parts of the body do not develop with the 
same rapidity. 

In 1866 Mr. Story, the sculptor, proposed a new canon, which in inge- 
nuity of detail and beauty of result is equal to any of its predecessors. To 
obtain this canon he directs that one-fourth of the entire height of the 
intended figure be laid down as the side of an equilateral triangle. " The 
triangle being completed, from its apex a line is to be dropped, bisecting 
the base, and extending below it a distance equal to one-third of its length 
above it ; this line forms the diameter of a circle, in which circle is inscribed 
a square. The diagram thus consists of a triangle and a square enclosed in 
a circle ; and when the lines of these figures are divided into thirds, fourths, 
etc., a vast number of dimensions are obtained, and in them all the measure- 
ments of the intended figure are to be found." 

From the " Silpi Sastri" of India to the " improved canon" of Story, 
it is instructive to observe what ingenuity and labor have been expended in 
these attempts to reduce human proportions to an exact system, and to 
notice the fallacy which pervades them all, — " that the key to the theory 



PHYSICAL DEVELOPMENT. 247 

is to be found in the occult relation of numbers or in the parts of a geo- 
metrical diagram." ^ 

It remained for observers like M. Quetelet, the distinguished mathema- 
tician, discarding theories, to recognize the existence of a central or typi- 
cal form of man, I'homme moyen, as the mean result of large numbers of 
actual measurements of living men, combining the aesthetic conception of 
the '' central form" of Sir Joshua Keynolds with the scientifically deduced 
" canon" of typical proportions of Prof. Cams. 

" A large number of naturalists and philosophers," M. Quetelet says, 
" have attempted to prove, by a course of reasoning which is more or less 
conclusive, the unity of the human species. I believe that I have succeeded 
in demonstrating not only that this unity exists, but that our race admits of 
a type or model the different proportions of which can be easily determined. 

" If there were an absence of type, and if men were unlike one another, 
not from the effects of accidental causes, but because no common law really 
existed among them, they might be measured, as regards height, for instance, 
without all the individual measurements offering any particular character or 
any definite numerical relation. 

" If, on the contrary, all men have to a certain degree been cast in the 
same mould, and if they issue from it with differences which are purely 
accidental, the groups will no longer be formed in an erratic manner, but 
their numerical values, in accordance with the theory of probabilities, will 
be subject to pre-established laws, so that the numbers which represent each 
man can be determined a priori. There exist, therefore, for this entirely 
special case, characteristics by which we may recognize whether individ- 
uals belong to the same type and only differ owing to fortuitous causes. 
Another consequence of the theory is, that the greater the number of obser- 
vations the more do fortuitous causes explain each other, and make the gen- 
eral type, which they at first tend to screen, stand out prominently. Thus, 
in the human race, when individuals only are considered, all heights are met 
with, at least within certain limits; those who come nearest the average are 
the most numerous ; those who deviate the most from it form the smallest 
number ; and the groups follow numerically a law (the binomial law of 
Newton) which may be laid down beforehand. In the case of man this law 
is verified not only in relation to the entire height, but also as regards his 
various members ; and the same is the case with the weight, or strength, or 
any quality which can be measured and reduced to numbers." ^ 



1 Baxter, op. cit., p. Ixix. 

2 Mean and Average. — The distinction between a mean and an average is often over- 
looked, or not clearly comprehended. Sir John Herschel so clearly exhibits it that the 
passage is worth quoting entire. Speaking of M. Quetelet's homme moyen, he says, " Now, 
this result, be it observed, is a inean, as distinguished from an average. The distinction is 
one of much importance, and is very properly insisted on by M. Quetelet, who proposes to 
use the word mean only for the former, and to speak of the latter (average) as the ' arith- 
metical mean.' We prefer the term average, not only because both are truly arithmetical 



248 



PHYSICAL DEVELOPMENT. 



The following diagram, taken from Roberts's " Anthropometrv," repre- 
senting the heights from actual measurement of four hundred and thirty 
English public-school boys from eleven to twelve years old, M'ill illustrate 
Quetelet's views : 

Fig. 1. 





Height 


Number 








IN 

Inches. 


OF 

Boys. 








60 


3 


Giants. 




59 


4 


\ 






58 
57 


12 


A 






36 
54 


\ 






\ 






54 
:,; 


79 




--^ 


Typical or 


1 mean boy 






59 


^ 


:^ 




51 


35 


^^ 






50 
49 


29 
12 


/ 






-/ 






. 48 


4 


/ 






47 


' 1 


I 


.„ Dwarfs. 









" It will be seen/' says Eoberts, '' that the numbers arrange themselves ac- 
cording to a very uniform rule ; the most numerous groups are in the middle 
of the column, at 53 and 54 inches, while the groups at 52 and 55 inches are 
Jess in number, and those at 51 and 56 inches are still fewer, and so on till 
the extremely small number of the very short and very tall boys of 47 
and 60 inches is reached. It is thus ascertained that the mean or typical 
boy of the class and age given is 53.5 inches, and, as representing the most 
numerous group, he forms the standard, from which the other groups of 
boys de<3rease in number as they dej^art further and further from his 
proportions. 

" In the diagram, which has been drawn to a scale, the length of the 
horizontal lines (abscissse) represents the numbers of boys in each group, 
and the curved line binding the ends tosjether is the well-known ' binomial 



means, but because the latter tenn carries already with it that vitiated and vulgar associa- 
tion which renders it less fit for exact and philosophical use. An average may exist of the 
tnost diiferent objects, as of the heights of houses in a town or the sizes of books in a library. 
It may be convenient to convey a general notion of the things averaged, but involves no 
conception of a natural and recognizable central magnitude, all differences from which 
ought to be regarded as deviations from a standard. The notion of a mean, on the other 
hand, does imply such a conception, standing distinguished from an average by this very 
feature, — viz., the regular march of the groups, increasing to a maximum and then again 
diminishing. An average gives us no assurance that the future will be like the past. 
A mean may be reckoned on with the most implicit confidence. All the philosophical 
value of statistical results depends on a due appreciation of this distinction, and acceptance 
of its consequences." — Edinburr/h Review, vol. xcii. ; Baxter, op. cit., p. Ixxviii. 



PHYSICAL DEVELOPMENT. 249 

curve/ or the ^ curve of the frequency of error.' Now, it will be seen that 
this curve is not quite uniform, and that the lower half (from the mean to 
the dwarfs) is less regular than the upper ; and if the numbers are counted 
it will be found that there are ten more boys below the mean than above it, 
consequently the average (obtained in the usual way, by dividing the sum 
of the values observed by the number of observations) is lower than the 
mean, which is represented by the largest group. The difference in this 
instance is not very great, the average being 53.43 and the mean 53.5 
inches, but in some instances it is much greater ; and it is exceedingly im- 
})ortant that the diiference here indicated should be borne in mind, for in it 
consists much of the practical value of Quetelet's method." 

Indeed, so exact are the methods of ]\I. Quetelet that a curious fact has 
been discovered in relation to dwarfs and giants, which, though in the gen- 
eral estimate considered as monstrosities, — anomalies of the human species, 
— are found to fall into their places as necessary factors in completing the 
scale of liuman stature. Moreover, it would be possible, if a correct esti- 
mation of the mean proportion of a population were made, to declare the 
number of each, and even the actual stature. 

AVhile M. Quetelet's method of studying the proportions of the body is 
the only scientific one yet propounded, and is the one now employed by all 
statisticians, the number of observations made by him are too few to be of 
any practical value, and the tables of Mr. Koberts, those of Prof. Bowditch, 
and the statistical results of the observations of Dr. John Beddoe, of 
17,000 observations obtained through the medical })rofession of Great 
Britain, the 12,740 Bavarian soldiers examined by Dr. Meyer, the exten- 
sive observations upon recruits of M. Boudin, and the examination of over 
one million men enlisted in the war of the rebellion in our own country 
(1,232,256), particularly the 23,624 men examined by the Sanitary Com- 
mission, have been employed in arriving at a correct scientific estimate of 
the " mean" man. 

The greater bulk of these observations is upon men, and, while they 
have no direct bearing upon development in children, they improve and 
correct the observations made upon children, and furnish more accurate 
data upon which to estimate physical culture, perverted development, and 
treatment of disease at this early period of existence. To emphasize this 
fact, the statement of M. Quetelet that children of the same sex are of the 
same size at twelve, and its correction by Drs. Roberts and Bowditch by the 
statement that at thirteen and fourteen years girls are taller and heavier 
than boys, may be cited. 

Methods. — In recording systematic measurements of the human body 
certain rules must be observed, in order to secure exactness, and for subse- 
quent reference and comparison. Prominent bony points — as the acromial 
extremity of the clavicle or the trochanter — are to be depended upon chiefly, 
although some soft parts, as the nipples in males, and the umbilicus, are 
sufficiently definite and fixed to be available. All measurements, if pos- 



250 PHYSICAL DEVELOPMENT. 

sible, must be taken upon the naked body, and heights taken without the 
shoes. The height is best obtained by measuring from the ground upward, 
although the various dimensions of the head are best obtained by measuring 
downward from the vertex. The diameters and circumference of the trunk 
are readily secured by means of callipers and a plain tape-measure marked 
in English inches and tenths of an inch. As the various trunk-measure- 
ments vary much with the state of the respiration, these are best deter- 
mined when the chest is empty and at rest, a condition easily secured by 
directing the person to count ten slowly in a loud voice immediately before 
the measurements are taken. The strength is best determined by making 
with the dynamometer several (three or four) trials each of grasping, pull- 
ing, and lifting, and estimating the averages. For recording all measure- 
ments the best methods and chart are those given by Mr. Roberts in 
his " Manual of Anthropometry," to which the reader is referred, or the 
blank forms published by the Anthropometrical Committee of the British 
Association, 22 Albemarle Street, London. 

The method extensively used in Germany, which consists in recording 
on a separate paper all the memoranda and observations relating to each 
individual case, reduces the labor of tabulation to a minimum and facili- 
tates the estimation of any particular observation. It should, therefore, 
always be employed. 

The following table may be taken as a good form upon which to record 
measurements. These should be repeated every three to six months, and 
comparisons made, or they may be plotted upon a percentage chart, such as 
are sold by dealers in general sporting goods, and compared with a standard 
or with hundreds of others similarly examined. 

TABLE FOE MEASUREMENT.! 



Date . 






1SQ . . 


Name .------ 


Ase 


years . 


...... months . , 


days 

.... pounds 


"Wei gilt 




Height 




.feet 


, . . . . inches 


Girth of head 

" n epic - - . . 


. . . feet 


inches 




right shoulder . . 
























chest inflated . . 








chest uninflated . 
lung capacity . . 




. cubic " 




















left thio-h . . 
















left calf . . . . 







1 From Physical Culture, A. J. Reach Co., Philadelphia. 



PHYSICAL DEVELOPMENT. 251 

TABLE FOR MEASUEEMENT.—( CoMr^mwerf.) 

Girth of right arm up inches. 

" left arm up " 

" right arm down " 

" left arm down " 

" right forearm " 

" left forearm u 

The relative and average growth in weight and increase in height have 
already been fully discussed in the article upon the physiology of infancy. 
There remain the general proportions and development of the head, neck, 
trunk, and extremities. It may be interesting here to observe that Que- 
telet has ascertained that in a large number of men (ten thousand, for exam- 
ple) of the same nation, age, and external surroundings, the same uniformity 
prevails as to weight that has been demonstrated to exist as to stature. 

As in height and weight, in addition to a large number of accidental 
causes, there are at least three factors which directly atfect the development 
of the different portions of the body in the growing child. These are 
nationality or race (Boudin), the occupation of the parents (Roberts), and 
the mode of life (Bowditch). 

M. Boudin, after comparing the results of his very extensive observa- 
tions, to determine the mean height of the inhabitants of different districts 
of France, with the researches of Broca, concluded that soil, local surround- 
ings, and climate exercise little influence on height, which is always an 
affair of race or hereditary descent. 

Mr. Roberts has demonstrated that the sons of English non-laborins: 
classes are decidedly taller, and at most ages also heavier, than the children 
of the laboring classes ; the difference amounting at thirteen years to nearly 
four inches, and this in a population comparatively stationary and homo- 
geneous in character. In our own country, Avhere the population is hetero- 
geneous, movable, and without class distinction, this principle is much less 
marked. Dr. Bowditch has, however, pointed out its existence, but con- 
cludes that the influence of mode of life in determining the size of growing 
children is at least equal to and possibly even greater than that of race. 

PROPOPvTIONS OF THE BODY. 

The different portions of the human body develop with varying rapidity 
at different periods of life, an observation already made in referring to Prof. 
Carus's " canon" of proportions. Of all these the head is most completely 
developed at birth and varies least during subsequent growth, for which 
reason, doubtless, it was early adopted as a standard of measurement. In 
the adult its relation to the entire height is one-seventh. From birth to 
adult life it doubles its height, while the remainder of the body increases 
three or four times, the growth being almost terminated at the age of ado- 
lescence. At birth the antero-posterior diameter (occipito-frontal, 11| 



252 



PHYSICAL, DEVELOPMENT. 



centimetres) is a little greater than the transverse (biparietal, 9^ centi- 
metres), and this ratio is maintained throughout life. The height varies 
little in the two sexes at diiferent periods of existence, as shown in the 
following table, taken from Quetelet : 



Age. 


Men. 


Women. 


Total 


Height of 




Total 


Height of 






Height, 


Head, 


Ratio. 


Height, 


Head, 


Ratio. 




Inches. 


Inches. 




Inches. 


Inches. 




Birth 


19.68 


4.37 


4.50 


19.44 


4.37 


4.45 


1 vear 


27.48 


6.06 


4.53 


27.16 


6.06 


4.48 


2 years 


31.14 


6.81 


4.57 


36.74 


6.77 


4.54 


3 " 


34.03 


7.16 


4.74 


33.64 


7.08 


4.74 


5 " 


38.86 


7.56 


5.14 


38.34 


7.40 


5.18 


10 " 


50.11 


8.07 


6.21 


49.37 


7.91 


6.21 


15 " 


59.56 


8.46 


7.04 


58.58 


8.38 


6.99 


20 " 


65.74 


8.93 


7.35 


61.96 


8.66 


7.15 


30 " 


66.37 


8.97 


7.39 


62.20 


8.80 


7.15 



The lower part of the face appears relatively to grow more rapidly 
than the upper ; the nasal incision, which at maturity divides the face into 
two equal parts, at birth is nearer the chin, — a circumstance which may be 
accounted for by the development of the alveolar processes and of the 
teeth, especially the molars. 

Neck. — At birth the neck is about one inch in length, but later, owing 
to the fatness of the infant's chin, it apparently shortens, and does not ap- 
pear to grow perceptibly till the sixth or seventh year, doubling its length 
by the time adolescence is reached. Its diameter develops rapidly during 
the first year, and again at puberty, and is practically the same in both 
sexes, being more rapidly attained, however, in the female, the diameter 
taken just above the clavicle measuring at birth about 1.81 inches, at six 
years 2.25 inches, and when fully developed about 4.75 inches. 

The development of the larynx in the male increases somewhat the 
upper circumference, and the development of the thyroid body in the 
female the lower circumference. 

Trunk. — The trunk includes the chest, abdomen, and pelvis, and is 
bounded above by the clavicles and below by a horizontal line on a level 
with the perineum. In length and transverse diameter the trunk-measure- 
ments from birth to maturity are tripled, while the head- and neck-measure- 
ments are doubled. The antero-posterior diameter, however, grows with 
less rapidity, increasing very slowly and regularly from birth, and doubling 
only at puberty. The circumference grows with the same rapidity as the 
transverse diameter : it is much modified after puberty in the two sexes, the 
shoulders being proportionately wider in the male, the pelvis in the female, 
the disproportion, which is, however, slight, being much enhanced in woman 
by the development of the breasts and by the modifying influence of her 
costume. This relative growth of the trunk in heio;ht and diameters is well 



PHYSICAL DEVELOPMENT. 253 

shown in the diagrams Nos. 2 and 3 opposite pages 97 and 113 respectively 
in Roberts's '' Manual of Anthropometry." 

The circumference of the chest, on account of the important organs which 
it contains, has been selected, together with the height and weight, to deter- 
mine the physical capacity of the individual for military, naval, and other 
public duties. The importance of these data in life insurance can hardly 
be over-estimated. From extended observation it has been ascertained that 
a direct ratio exists between the height, weight, circumference of chest, 
and age, and formulas have been arranged somewhat arbitrarily by which to 
ascertain from the stature the circumference of the chest. It is not well, 
however, to follow these formulas too dogmatically, as Baxter's conclusions 
prove that Mr. Hutchinson's and Mr. Brent's formulas do not correspond 
when applied to the examination of immense numbers of able-bodied men, 
representing the picked men of the nation. From these it is observed that 
the figures do not rise above the minimum size of the chest, nor do they in 
any instance attain the medium size} 

If the mobility of the chest be very limited, this should also be re- 
garded as a disqualification for military service, or else should lead to more 
thorough physical examination. The degree of mobility varies much in 
different individuals, and is also modified by sex, the female chest, particu- 
larly the upper portion, being more active, but limited in extent. The 
healthy man's expansion, according to Hutchinson, is three inches (Baxter, 
3.08), but may reach even seven inches. A remarkable instance was ob- 
served in a native of New Jersey admitted to the service, Avho was eighteen 
years of age, Aveighed one hundred and fourteen pounds, and was sixty-four 
inches in height; his chest at expiration measured twenty-nine inches in 
girth, and had an expansion of seven inches. 

Upper Extremities. — The upper extremity, including the arm, fore- 
arm, and hand, varies much in development. The popular idea that the 
space covered by the extended arms is equal to the height is correct only for 
early life, — before puberty, — being the same in both sexes. After puberty, 
however, in man, owing to the increased breadth of the shoulders, the hori- 
zontal measurement exceeds the perpendicular, and in Avoman it is also 
slightly greater. The arm, measured between the acromion and the external 
condyle, increases in length from 3.5 inches in the infant to 13 inches in 
the adult, and in circumference from 4 to 12 inches, these measurements, 
however, being greatly influenced by exercise, sickness, etc. 

The adult forearm (cubit) was the unit of measurement among the 
ancients. The growth of the forearm in length, measured from the ex- 
ternal condyle to the styloid process of the radius, is from 2.25 inches in 
the infant to 9| inches in the adult, and its increase in circumference from 
2.5 inches in the child to 13f inches in the adult. Its circumference is also 
much influenced by exercise. 

^ For more detailed information the reader is referred to Baxter, vol. i. p. 43. 



254 PHYSICAIi DEVELOPMENT. 

The hand, as employed by artists, sculptors, and others, represents the 
ratio of 1 to 9 of the entire height. It develops slowly, being doubled in 
length by the seventh year, and tripled at maturity. It is a little broader 
and plumper in proportion to length in women than in men. 

The length of the entire upper extremity, measured from the acromion 
extremity of the clavicle to the tip of the middle finger, is doubled between 
the ages of four and five, tripled by puberty, and quadrupled by maturity, 
— growing with less rapidity than the lower extremity, which during the 
same period is quintupled. 

Lower Extremities, — The lower extremity includes the thigh, the 
leg, and the foot, and is the most important factor in determining the height 
of the individual. The thigh, included between the trochanter and the 
patella, increases in length from 2.75 inches in the infant to 18 inches 
in the adult, an increase of nearly sevenfold, the greatest increase of 
growth observed in the body. After puberty the increase is relatively 
greater in the female, owing to the increased width of the pelvis and the 
development of the upper thigh. For the same reason, the angle formed 
laterally at the knee, between the thigh and the leg, is also relatively 
greater in the female. 

The leg, included between the lower edge of the patella and the in- 
ternal malleolus, increases from 3.4 inches in infancy to 15.3 inches at 
maturity, an increase which is much modified by exercise and somewhat 
also by sex. 

The foot has been much employed as a unit of measurement, its length 
being in both sexes and at all ages from .15 to .16 of the entire height. 
The belief that its length corresponds to the height of the head and the 
circumference of the fist is fallacious. It grows in height from 1 inch at 
birth to 3.25 inches at maturity, and in length more rapidly than in height, 
from 3-3.5 inches at birth to 8-10 inches at maturity. Its width is pro- 
portionately greater in the male, and is much influenced by race-peculiarities 
and by dress. 

The length of the lower extremity increases more rapidly than that 
of any other portion of the body, being doubled before the third year, 
quadrupled before puberty, and increased fivefold by maturity, the thigh 
growing more rapidly than the leg, and the leg than the foot. 

In this connection it must be borne in mind that the human frame is 
subjected to many influences that tend to produce minor deformities, con- 
genital and acquired, all, however, within the bounds of health, as unequal 
development of the lower extremities, transposition of viscera, excessive 
development of the right side, etc. 

The relative proportions of a perfect female form, as deduced by modern 
sculptors from the Greek statues, may be stated as follows. With a 
height of five feet five inches, one hundred and thirty-eight pounds is the 
proper weight, which, however, could be increased ten pounds Avithout 
greatly destroying the proportion. When her arms are extended, she 



PHYSICAL, DEVELOPMENT. 



255 



should measure from tip of middle finger to tip of middle finger just five 
feet five, exactly her own height. The length of her hand should be just a 
tenth of that, and her foot just a seventh, and the diameter of her chest a 
fifth. From her perineum to the ground she should measure just what she 
measures from the perineum to the top of the head. The knee should 
come exactly midway between the perineum and the heel. The distance from 
the elbow to the middle finger should be the same as the distance from the 
elbow to the middle of the chest. From the top of the head to the chin 
should be just the length of the foot, and there should be the same distance 
between the chiu and the armpits. A woman of this height should measure 
twenty-four inches about the waist, and thirty-four inches about the bust if 
measured from under the arms, and forty-three if measured over them. 
The upper arm should measure thirteen inches, and the wrist six. The 
calf of the leg should measure fourteen and a half inches, the thigh twenty- 
five, and the ankle eight. 

When full development has been attained, the relative proportions of 
a perfect male may be summarized as follows : 

TABLE 1 

Shoioing the Proper Weight, Height, and Measurement of a FuUy-Developed Man. 



Height. 


w 




< 


H 

W 

a 


S 


< 

63 


w 
o 

s 

E-i 


> 

< 


5 feet, 


103-107 


lU 


29 


32-33 


OJ 


81 


15 


o 


6 " 1 inch, 


107-111 


11.^ 


29 .V 


33-34 


'^ 


91- 


16 


-^ 


5 " 2 inches, 


111-116 


12 


30 


34-35 


=M 


9| 


17 


=2 


5 " 3 " 


116-121 


12.V 


30^ 


35-36 




10 


18 




5 " 4 " 


121-127 


13 


31 


36-37 




10| 


19 




5 " 6 " 


127-133 


13.^ 


3U 


37-38 


0) ,J 


10| 


20 


§ ''. 


5 " 6 " 

5 " 7 " 


133-140 
140-147 


14 


32 
32J 


38-39 
39-40 


S cy 


Hi 


21 
22 


9 o 


5 " 8 " 


147-155 


15 


33 


40-41 


S 


11 J 


23 


to 


5 " 9 " 


155-164 


15i 


33.^ 


41-42 


CJ 


12 f 


24 


<D 


5 " 10 " 


164-174 


16 


34 


42-43 


C 


12i 


25 


fl 


5 " 11 " 


174-185 


16J 


34.V 


43-44 




13 


26 


rH 


6 " 


185-196 


17 


35 


44-45 


OS 


13| 


27 


m 



EXERCISE. 



The term " exercise" is applied physiologically to any exertion or action 
of the body for the maintenance of its organs or functions in a healthy 
condition, but in a more restricted and generally accepted sense applies to 



1 From Physical Culture, A. J. Reach Co., Philadelphia, p. 52. 

'•^ This rule has long heen observed, especially among artists, but it is not true to 
life, for very rarely do we find either men, women, or children whose neck, upper-arm, 
and calf measurements are the same. As a rule, the upper arm is the smallest of th^ 
three. 



256 PHYSICAL DEVELOPMENT. 

certain movements of the body eflPected by the contraction of the voluntary 
muscles made with sufficient force and rapidity to quicken the breathing 
and accelerate the circulation of the blood, — in other words, muscular 
exercise. The muscles acted upon during exercise are all of the striped 
variety, — the skeletal muscles, heart, diaphragm, etc. ; but a marked dis- 
tinction must be observed between these muscles, from the fact that, 
although practically of the same structure, the nervous control differs, the 
heart and diaphragm not being under the control of the will, and their 
action being only secured secondarily through the effects of the action of 
the voluntary muscles. 

The muscles consist essentially of the sarcous substance, with its nuclei 
■or muscle-corpuscles enclosed within compartments, and surrounded by the 
sarcolemma and endomysium and perimysium, so as to consist of fasciculi 
or bundles of fibres surrounded by connective tissue. These fasciculi are 
connected ultimately by tendinous fascias or bauds with the osseous struc- 
tures upon which they are intended to operate. The sarcolemma through 
a single opening receives the axis-cylinder of a nerve-fibre, which after 
forming a flat protuberance — or motor end-plate — is distributed in fine 
fibrils throughout the cell-contents. Sensory as well as motor nerve-fibres 
are distributed to the muscle-substance, to convey impressions to the cen- 
trally situated nerve-cells. By a fine mesh-work of capillaries lying be- 
tween and upon the fibres and cells, but without penetrating the sarcolemma, 
the muscles are bountifully supplied with blood. 

Muscles are at rest neutral or slightly alkaline in reaction, and consist 
chemically by weight of three-fourths water and one-fourth nitrogenous 
and non-nitrogenous matters and salts. The most important nitrogenous 
element is the coagulated substance which becomes in dead muscle myosin, 
which is found in much smaller quantities in infants than in adults. 
Among the non-nitrogenous matters, paralactic or sarcolactic acid may be 
mentioned, while the salts are principally the alkaline compounds found 
most abundantly in the blood, these salts and other extractive matters 
being much more plentiful in infant than in adult life. 

Function of Voluntary Muscles. — The characteristic physiological 
property of muscle is its contractility, by virtue of which all its acts are 
performed. The muscular system in infancy is very poorly developed, so 
that during childhood and youth the increase, both relative and absolute, is 
enormous. In its elongated condition of rest, muscle is still under a slight 
degree of tension (muscular tonus, or muscular tonicity), and under the 
influence of appropriate electrical or nervous stimulus it becomes shorter 
and thicker and its extremities are approximated. With increased stimula- 
tion the corresponding contraction will be found to increase, and finally will 
diminish until contraction ceases entirely through the muscle being fatigued 
from repeated stimulation. The more rapid the contraction the more 
quickly does the fatigue manifest itself and the longer is the period of rest 
required to recuperate its full power. As might also be expected, a muscle 



PHYSICAL DEVELOPMENT. 257 

will become fatigued much sooner when it does work than when it simply 
contracts without doing work. The muscles in contracting must exert a 
force sufficient to elongate the opposing muscles, must overcome the force 
exerted by the tonicity of the antagonizing muscles, and must lift the weight 
of the portion of the limb to which they are inserted. When, on the other 
hand, this force, known as antagonistic force, is withdrawn by paralysis or 
section of the tendons, undue action is at once manifested in the opponents. 
The vibrations of muscular contraction can be distinctly heard if the stetho- 
scope or myophone be applied over a powerfully-contracting muscle, as the 
biceps, or the heart during its first sound. 

During contraction the reaction of the muscles becomes distinctly acid, 
from a considerable amount of carbonic or lactic or sarcolactic acid being 
set free. With use the muscles increase in size, in firmness or tone, and in 
strength, and respond more quickly to stimuli, good examples of which are 
exhibited in the bulky biceps of the blacksmith and the colossal calf of the 
ballet-dancer. When a single muscle or a group of muscles is exercised too 
much, it will, after increasing greatly in size, begin to waste. This, how- 
ever, is not the case lohen all the muscles of the body are exercised, probably, 
as Parke suggests, because no one muscle can then be over-exercised. 

JNIuscuLAR Work. — The work performed by muscular contraction rep- 
resents but a fractional part — about one-ninth, or over ten per cent. — of 
the entire work done in the body ; the nervous energy, or internal work, 
as it is called, — the force required to regulate the various processes of 
digestion, assimilation, and secretion, for intellectual pursuits, etc., and the 
caloric work, or the force required in the production of heat to maintain the 
bodily temperature, — constituting the larger proportion. It must be re- 
membered that the heat-units employed in the internal work of regulating 
the circulation and perspiration are only temporarily converted into mechan- 
ical energy, the latter being almost entirely reconverted into heat by the 
function developed by various obstructions offered to the movement of the 
blood and respiratory organs. However expended, or however it may vary 
in amount, the force is the same, and its amount may be estimated and its 
source be discovered. " The work done by a muscle in a given contraction, 
when it lifts a weight vertically against gravity, is measured by the weight 
moved multiplied by the distance through which it is moved." ^ 

It has been found, from calculations made by different observers, that 
the amount of force expended daily by an adult weighing one hundred and 
fifty pounds in the performance of these three forms of work is about three 
thousand four hundred foot-tons, — or a force required to raise three thou- 
sand four hundred tons one foot in height, — the greater amount of which 
(two thousand eight hundred and forty) is employed in maintaining the 
animal temperature, the remainder being distributed between the internal 
force (two hundred and sixty) and muscular activity (three hundred). 

1 Sargent, Physical Training Conference, 1889, p. 71. 
Vol. IV.— 17 



258 PHYSICAL DEVELOPMENT. 

Estimates made upon the actual labor expended in performing certain 
manual acts by men of the same weight, such as eight hours' pile-driving, 
turning a wrench, carrying a peddler's pack, paving, etc., demonstrate 
the same fact. From estimates of this character, and considering that the 
type of the most healthy life is that of a man engaged at moderate labor in 
the open air, at which work he will proljably average between two hundred 
and fifty and three hundred and fifty foot-tons, Prof. Parkes has concluded 
that a healthy adult should bear without the risk of over-fatigue what 
would be equivalent to a walk of nine miles, from which must be deducted 
the exertion used in ordinary business pursuits. 

The source of this force or energy must be sought in the molecular life 
or combustion going on through the entire economy. In every action of 
the human body, — whenever we make a movement, draw a breath, change 
a muscle of expression, or conceive a passing fancy, — molecular death has 
occurred, and a quantity of potential energy (force) has been liberated. This 
force, having previously entered the body in a latent state as food, was 
stored by means of the blood in the cellular structures awaiting the demand 
for its ignition with the oxvo;en circulating in the blood. These disinte- 
grated cellular elements, removed by the blood to be eliminated from the 
system, are replaced by new active cells, and thus the unbroken circle of 
physiological phenomena — latent potential energy, motion or activity, cell- 
destruction, cell disintegration and elimination, cell-renewal, more latent 
force, and so the same succession of events — is maintained, and at every 
revolution vital, active (kinetic) force develops. This, in a Avord, consti- 
tutes "life;" and upon the celerity and thoroughness with which these 
processes are repeated — upon the " newness," as Maclaren has expressed 
it, of the individual cells — will depend the health and strength of the 
individual. 

MoTiox AXD Heat. — This force, then, which is the result of the oxy- 
genation, death, or burning up of the cellular elements of the body, suggests 
at once the relationship which exists between heat and motion, the correla- 
tion existing between them, and the conversion of one into the other. Con- 
ceived by Sadi-Carnot, clearly formulated by R. Mayer, brilliantly demon- 
strated by Joule, the theory of the equivalence of forces may now be said 
to be admitted by all physicists, and the mechanical equivalent of heat be 
considered as 425. 

As before stated, nearly sixty per cent, of the work performed in the 
body is employed in the production of heat or in muscular exercise, and 
we shall now see that probably three-fourths of the heat developed is pro- 
duced in the muscles at the moment of muscular contraction. Daily obser- 
vation and special experiments teach us that the whole body is heated by 
muscular exercise, and Davy found that after a walk in the open air, the 
temperature of the surrounding atmosphere being 40° F., the tempemture 
of the urine was elevated one degree, — from 100° to 101° F. This devel- 
opment of heat by muscular contraction is also well seen under certain 



PHYSICAL DEVELOPMENT. 259 

pathological conditions, — for example, in tetanus rising, according to Wun- 
derlich, to the extreme height of 112.5° F., although this extreme temper- 
ature can hardly be attributed entirely to muscular action. 

The theory of the close relationship between calorification and com- 
bustion, poetically expressed by the philosophers of antiquity as the fire 
snatched from heaven, the flame of jprometheus, and described so accurately 
by Lavoisier more than a century ago, remains substantially the accepted 
view of modern times, the only modifications consisting in the implication 
of the theory of caloric, and in considering the lungs not alone the seat of 
the chemical interchange. 

Natural philosophy furnishes numerous examples of motion converted 
into heat by friction, etc., and also of the conversion of heat into motion, 
of which the steam-engine is a practical example. In the human economy, 
the various systems, but particularly the muscular, may be regarded as so 
many machines for converting the potential energy derived from the food 
and oxygen into mechanical force, with this exception, however, that the 
muscles are more economical in their action than the finest engine could 
possibly be. Food and oxygen are taken into the system, potential energy 
and bodily temperature are produced, and it remains to estimate the heat- 
value and force-value of the different principles of food. 

To ascertain the heat-units, and to deduce the force-value or units of 
motion from these, Favre and Silbermau first, and later Prof. Franklaud 
by means of the calorimeter, determined by experiment the amount of 
heat developed by the combustion of different articles of food within and 
outside the body. It was found that the fatty and carbohydrate foods 
were as thoroughly burned in the body as without, though more slowly, 
while the nitrogenous (albuminous) substances were but imperfectly con- 
sumed, corresponding exactly with what occurs within the system. Upon 
the same principle Ranke performed his admirable experiments upon him- 
self. From these and the experiments of Vierordt and Voit a sufficiently 
accurate estimate of the force-value of the different elements of food may be 
formed. 

According to the reduced table of Prof. Frankland as given by Ralfe, — 

15 grains of dry albumen (fleshy matter) = 13,851 foot-pounds. 
15 grains of fat of beef = 27,716 " 

15 grains of starch =11,720 " 

" If, therefore," says Ralfe, " 1800 grains of dry albumen, 1350 grains 
of fat, 4900 grains of starch, be daily consumed, an amount of force capa- 
ble of lifting 7,910,045 pounds to the height of one foot, or 3530 foot-tons, 
Avill be derived from the food; a result closely corresponding with the 
calculated estimate of the total work done in the body, — viz., 3400 foot- 
tons." The former popular fallacy that the principal source of muscular 
force was from the combustion of the albuminous, fleshy principle has 



260 PHYSICAL DEVELOPMENT. 

happily been disj^elled, and the relative value of albumen, fats, and starches 
is appreciated. 

It will be recollected that the strongest men are not always meat-eaters, 
and that the rhinoceros and the elephant, animals noted for their strength, 
are strictly vegetarians. Indeed, the opinion has been expressed by a good 
authority that different muscular qualities are developed by flesh and fari- 
naceous food, the leopard and the deer being given among animals as illus- 
trations : the leopard with the quick action engendered by fleshy food has 
the advantage of the deer, but the latter with the slow force developed by 
its farinaceous diet can outstrip the leopard in fair chase. 

While the limits of this article will not permit of any discussion of 
general muscular movements, involving necessarily a detailed description 
of the muscles and general anatomical structures of the joints and the 
thorough consideration of animal mechanics, a short account of how the 
ordinary movements are accomplished Avould seem an appropriate introduc- 
tion to a description of the varieties of exercises employed in physical 
culture. The skeletal muscles may be regarded for the most part as so 
many sources of power arranged to act upon the bones and cartilages as 
levers. The three forms of levers recognized in ordinary mechanics, from 
the relative position of the power, the weight to be moved, and the axis 
of motion or fulcrum, are all represented in the human economy, examples 
of the first kind being rare, and those of the third kind being more common 
than the second. 

This preponderance of the third class of levers is probably due to the 
fact that the movements of the body are chiefly directed to moving com- 
paratively light weights through a great distance, or through a short dis- 
tance with great precision, rather than to moving heavy weights through a 
short space. A familiar example of the first order, where the power is 
at one end, the weight at the other, and the fulcrum in the middle, occurs 
when the body is raised from the stooping position by the action of the 
hamstring muscles attached to the tubera ischii. The second order, where 
the power is at one end, the fulcrum at the other, and the weight in the 
middle, is illustrated in the depression of the lower jaw in opening the 
mouth, the temporals and masseters representing the weight. The third 
order, where the fulcrum is at one end, the weight at the other, and the 
power in the middle, is best represented by the action of the biceps muscle 
upon the forearm. 

All these orders of levers may be beautifully illustrated in the different 
movements of the foot, — the first where the heel is raised and the toe is 
tapped upon the floor, the heel representing the power, the ankle-joint the 
fulcrum, and the toe the weight ; the second where the body is raised upon 
the toes, the ground representing the fulcrum, and the body the weight ; 
and the third where the foot is flexed and elevates a weight resting upon 
the toes, the ankle being again the fulcrum. 

There are few movements of the body in which one muscle only is 



PHYSICAL DEVELOPMEMT. 261 

concerned. In the majority of cases several muscles act together, nearly 
all the movements are co-ordinate, and genemlly the power is so disposed 
with reference to the fulcrum that in acquiring a greater range of motion 
the power is diminished. 

Animal Mechanics. — Every movement of the body depends as much 
upon the proper co-ordination of the muscles for its accuracy, grace, and 
force as upon the strength of their contraction ; and particularly is this true 
of the exceedingly complex movements of walking, running, jumping, etc. 
To appreciate these best, some knowledge must be had of the manner in 
which the upright position is maintained. In the erect posture the weight 
of the entire body is borne by the plantar arches, by a series of muscular con- 
tractions of the lower extremities, trunk, and neck, having for their object 
the maintenance of the body in such a position that the line of gravita- 
tion falls within the area of the feet. That this is the result of muscular 
action, at one time denied, is proved by the facts that a person standing 
perfectly at rest in a balanced position falls when unconscious, and that 
a dead body cannot be balanced upon its feet. The line of gravity passes 
from the vertex of the head in front of the occipital articulation, in front 
of the tenth dorsal vertebra, behind a line joining the centres of the two 
hip-joints, a little behind the knee-joints, to reach the earth in front of the 
centre of a line drawn between the two ankle-joints. The centre of gravity 
for the entire body is located at the end of the sacrum, and for the combined 
head and trunk about the level of the ensiform cartilage in front of the 
tenth dorsal vertebra. The somewhat unstable equilibrium of the erect 
position is maintained without much difficulty by keeping this line within 
the area of the basis of support ; otherwise, when the line falls outside this 
area, the tendency of the body is to fall, unless overcome by strong muscular 
action. 

In maintaining the body in this erect position almost all the muscles of 
the lower extremity, trunk, and neck are concerned. While the line of grav- 
ity remains within the area of the feet, the slight muscular effort required is 
little more than the tonicity contained in all living muscle. The head and 
neck are maintained from falling forward or backward by the combined 
action of the trapezius, levator anguli scapulae, splenius, cervicalis asceudens, 
trausversalis colli, trachelo-mastoid, spinalis colli, complexus, multifidus 
spinse, interspinales, rectus capitis posticus minor, and obliquus superior, 
acting as backward flexors against the platysma myoides, sterno-cleido- 
mastoid, rectus capitis auticus major, rectus capitis anticus minor, longus 
colli, scalenus anticus medius and posticus, digastric, sterno-hyoid, sterno- 
thyroid, omo-hyoid, mylo-hyoid, and genio-hyoid as forward flexors ; the 
position laterally being maintained by the platysma myoides, sterno-cleido- 
mastoid, trapezius, splenius, trachelo-mastoid, complexus, the three scaleui, 
rectus capitis posticus major, intertrausversalis, and rectus lateralis. 

The line of gravity falling in front of the occipital condyles, the ten- 
dency of the head is to fall forward, demanding naturally greater action of 



262 PHYSICAL DEVELOPMENT. 

all the posterior group of muscles and ligaments (particularly the ligamentum 
uucbse), which of necessity are better developed. 

The trunk is maintained from falling backward by the action of the 
rectus abdominis, pyramidalis, obliquus externus, obliquus internus, and 
psoas maguus and parvus, assisted by the pectoralis major and minor, serra- 
tus magnus, transversalis, pectineus, adductor longus, adductor brevis, rectus 
femoris, sartorius, and all those muscles which pass from the pelvis to the 
internal condyle and shaft of the femur ; and from falling forward by the 
action of the glutei (magnus, medius, and minor), latissimus dorsi, serratus 
posticus inferior, and all the larger dorsal muscles, assisted by the scapular 
muscles, — rhomboidei, inferior portion of the trapezius, etc., which fix the 
scapulae backward and approximate them to the skeleton. It is maintained 
laterally by the obliquus externus, obliquus interuus and transversalis, 
quadratus lumborum, longissimus dorsi, and sacro-lumbalis. 

The rigidity of the body upon the thighs is secured by the contraction 
of the psoas maguus, iliacus, sartorius, pectineus, three adductors, gracilis, 
gluteus minimus, obturator externus, tensor vaginae femoris, and rectus 
femoris, as flexors acting agaiust the gluteus maximus and medius, pyri- 
formis, obturator interuus, gemelli superior and inferior, quadratus femoris, 
long head of biceps, posterior portion of adductor magnus, semi-tendinosus, 
and semi-membranosus acting as extensors ; the position being secured 
laterally by the three glutei, tensor vaginae femoris, pyriformis, gemelli, 
sartorius, and obturator interuus, acting as abductors against the three 
adductors, psoas magnus, iliacus, pectineus, quadratus femoris, obturator 
externus, gracilis, semi-tendinosus, semi-membranosus, and long head of 
biceps acting as adductors. 

The rigidity of the legs upon the thighs is maintained by the biceps, 
semi-tendinosus, semi-membranosus, gracilis, sartorius, gastrocnemius, plan- 
taris, and popliteus acting as flexors, and the quadriceps femoris (rectus 
femoris, vastus externus, and crureus) acting as extensors. 

The relation of the foot at an angle of ninety degrees to the leg is main- 
tained by the gastrocnemius, soleus, plantaris, and peroneus longus, as 
extensors; the tibialis anticus, peroneus tertius, and extensor longus digi- 
torum, as flexors : the tibialis anticus, tibialis posticus, and flexor longus 
digitorum, as adductors ; and the three peronei (peroneus longus, brevis, 
and tertius), as abductors; the arch of the foot being supported princi- 
pally by the peroneus longus, the interosseous ligaments (chiefly the inferior 
calcaneo-scaphoid and calcaneo-cuboid), and the plantar fascia. 

" It may be instructive here to review briefly the anatomical construction 
and mechanism of the natural foot. The foot includes all that portion of 
the inferior extremity below the tibio-tarsal articulation, consisting of the 
tarsus, metatarsus, and phalanges, and in the adult has the form of two 
arches, an antero-posterior and a transverse, each Avith its convexity or 
dorsal surface above and its concavity or plantar surface below. The 
antero-posterior, the most important, is supported upon two piers or pillars, 



PHYSICAL DEVELOPMENT. 263 

and has its summit at the astragalus and ankle-joint. This has been still 
further divided into two arches, an outer and an inner, by an imaginary 
line drawn posteriorly between the third and fourth metatarsal bones ; the 
inner portion of the antero-posterior arch is much more curved than the 
outer, and forms the instep. The posterior pier, formed by the posterior 
parts of the astragalus and os calcis, is shorter, more curved, has but one 
joint, and is more solid, receiving the greater part of the weight of the body. 
The anterior pier, composed of the scaphoid, three cuneiform, and three 
inner metatarsal bones, is longer, less curved, has many joints, and is more 
elastic, serving to diminish the force of shocks transmitted to the arch. 
The head of the astragalus fitting into the concave surface of the scaphoid, 
and its postero-inferior surface articulating with the anterior surface of the 
OS calcis, it may be regarded as the keystone, though diifering in many 
respects from such bodies as usually employed. The weak part of the arch 
is strengthened by the interosseous ligaments, particularly the inferior cal- 
caneo-scaphoid, which supports it from below, while those beneath the inner 
portion of the plantar fascia add additional strength. The outer portion 
of the antero-posterior arch consists of the outer portion of the os calcis, the 
cuboid, and the two outer metatarsal bones. It is strengthened by the cal- 
caneo-cuboid ligaments and the outer portion of the plantar fascia. Both 
arches are still further maintained by the tibialis posticus and peronei 
muscles, particularly the peroneus longus. The transverse arch, formed in 
the inner and outer sides by the bones entering into the inner and outer 
antero-posterior arches respectively, varies in degree of curvature in diifer- 
eut portions of the foot, being most marked across the cuneiform bones. 
It affords protection to the soft parts of the sole, and adds to the elasticity. 
The weight of the body is received by the astragalus as the highest part of 
the arch, and transmitted to the ground through the two piers of the autero 
posterior arches. The foot in extension rests normally upon the heel, the 
tips of the metatarsal bones, and the outer side of the sole, the weight of 
the body in standing, walking, running, or dancing being transmitted 
through the heel, the ball of the great toe, and that of the little toe, — the 
natural tripod of the foot, — in the order named. Thus the direction of the 
weight upon the arches is constantly changing, and it is only through the 
actions of certain muscles that the normal arches are conserved. Thus, in 
flexion the antero-posterior arch is increased by the action of the tibialis 
anticus, peroneus tertius, and extensor longus digitorum ; and in extension, 
by the action of the gastrocnemius, soleus, plantaris, and peroneus longus, 
both the curves are diminished and the foot is flattened. Then, also, Avhen 
the foot is markedly flexed, the foot is adducted, in which position the arches 
are each respectively increased and diminished. In this connection Mr. Le 
Gros Clark says, ' In reviewing the actions of the various muscles around 
the foot, it is obvious that their attachment is designed to preserve the plan- 
tar arch, and that such healthy condition must depend in a great measure 
on the evenly-balanced action of those muscles upon their several attach- 



264 PHYSICAL, DEVELOPMENT. 

ments. Thus, the peronei aud tibial muscles antagonize each other, and the 
expanded insertion of two of them into the tarsal bones is very instrumental 
in preserving the transverse as well as the antero-posterior arch.' " ^ 

Locomotion. — It is necessary here to refer briefly to the methods em- 
ployed in the study of animal locomotion, in order to obtain a proper con- 
ception of this important subject. While the work of the Weber brothers 
and the earlier studies by means of the graphic method of MM. Marey, 
Carlet, and Mathias Duval were excellent so far as they extended, they 
gave but an imperfect idea of the complicated mechanism of animal loco- 
motion. To remedy the defects of the graphic method, Marey first and 
Demeny later invoked the aid of photography, but even the results thus 
obtained give but meagre information of the lateral sway. The earlier 
authors employed the zoetrope — an ingenious optical instrument invented 
by Plateau, which presents to the eye a series of successive images so co- 
ordinated by rapid revolution as to bring before the eye all the phases 
of a movement — to overcome these defects; and Marey, well aware that 
his photographs gave no information of the direction or extent of the lateral 
sway, endeavored to remedy this by an ingenious application of the stere- 
oscope to his photographic wheel. This addition to the pictures gave the 
impression of an undulating white baud extending through space, the un- 
dulations being in three directions, forward, vertically, and laterally, but 
did not admit of detailed study of the curves. 

It remained for Mr. Eadweard Muybridge, of Philadelphia, so to util- 
ize photography and electricity as to produce results almost, if not entirely, 
perfect. These possess the decided advantage over all similar efforts of 
admitting of a detailed study not only of the curves, but also of the for- 
ward, vertical, and lateral movements of the various points of the body. 

Notwithstanding the various slight sources of error in Mr. Muybridge's 
methods, pointed out by Dercum, these photographs have contributed more 
than anything else in modern times to facilitate the study of animal motion 
and locomotion. These photographs, when placed in the ingenious instru- 
ment, invented by Mr. Auschuetz, known as the tachyscope, — which con- 
sists of a series of pictures so placed on a circular glass plate revolving 
rapidly on its axis that whenever a picture appears before the eye of the 
observer it is lit up by an electric spark, — produce a bit of life with a 
degree of truth and accuracy that are absolutely bewildering. Take, for 
example, the hurdle jump of a race-horse, which occupies seventy-two one- 
hundredths of a second, or the slower movement of a man on a galloping 
horse : the illusion is perfect. One sees not only the legs move according 
to the gait, but the dust rise, the horse's mane and tail fly, the nostrils 
dilate, the rider urge his horse, pull the curb, aud move back his leg to 
apply the spur. 

Mr. Muybridge's method consists in making simultaneous serial photo- 

^ Young, New York Medical Kecord, iii. 10. 



PHYSICAL DEVELOPMEXT. 265 

graphs of a moving man or animal at from two to four points of view at 
right angles with one another. While the serial method gives slightly less 
accurate results regarding the rise and fall and onward movement of a limb, 
taken all in all it more than compensates for the slightly- varying angle at 
which the photographs are taken, by permitting the determination of the 
direction and amount of the lateral sway, and gives an opportunity for the 
study of a part which a wheel photograph could not furnish. The draw- 
ings from Dercum exhibit the squares and display the scientific character 
of the work, but in the other original drawings these have been omitted, 
though they are none the less correctly drawn. 

Walking. — Walking has been described as being " a constant falling 
forw^ard, where the weight of the body is received by each leg alternately." 
In walking there is in each step a moment when the weight of the trunk 
is supported upon the foot of one extremity (say the left) by the combined 
action of the flexors and extensors of the extremity and the abductors 
of the opposite side (see p. 261), while the other (the right) is inclined 
obliquely behind, the heel raised by the action of the gastrocnemius, soleus, 
flexor longus poUicis, flexor lougus digitorum, tibialis posticus, and peroneus 
longus, and the toe resting upon the ground. The body balanced upon the 
left foot, by the combined action of the flexors and extensors of the hip, 
thigh, leg, and foot, and the abductors of the right side of the body, the 
weight of the body is thrown principally upon the glutei, inferior dorsal 
muscles, and abductors of the right side of the trunk. The right thigh is 
flexed by the psoas magnus, iliacus, biceps, gluteus medius, anterior part of 
the gluteus magnus, gracilis, sartorius, gastrocnemius, plantaris, and popli- 
teus ; to avoid contact with the ground the leg is swung forward pendulum- 
like by the relaxation of the flexors, and the contraction of the extensors of 
the thigh and of the knee, principally the quadriceps extensor femoris. This 
contraction of the extensors of the knee makes the pendulum-like motion 
of the right leg, and contributes to the forward motion in walking, the 
length of the s-wing varying with the length of the limb, and the right 
heel, the side of the foot, and the ball of the great toe are brought in contact 
with the ground. 

On this right toe as a fulcrum the body is moved forward by the action 
of the extensors about the hip, particularly the gluteus maximus, and the 
lateral muscles of the trunk (see p. 261), describing both a vertical and a 
lateral curve, the right leg becoming straight and rigid by the combined 
action of all the muscles of the lower extremity. 

With another forward movement of the pelvis the starting-point is 
again reached, the body supported vertically upon the right foot as before, 
and the left foot directed in an oblique position behind. This forward 
movement of the right foot carries the pelvis beyond the vertical, and in so 
doing swings the left leg forward by the action of the psoas magnus and 
iliacus, assisted by the sartorius, pectineus, gracilis, gluteus minimus, obtu- 
rator externus, tensor vaginae femoris, and rectus femoris, until its heel, side 



266 



PHYSICAL DEVELOPMENT, 



of sole, and ball of great toe in turn form the fulcrum on which the pelvis 
moves, and tlie right leg is again swung forward. In this manner the head 
and pelvis describe a series of concentric curves with their convexities 
upward. (See Photo. I.) 

This regular and alternate movement of the support of the body from 
one foot to the other in walking necessitates a lateral displacement of the 
line of gravity, so that the centre of gravitation is constantly describing a 
consecutive series of horizontal (lateral) curves in addition to the vertical 
ones already described. This is particularly noticeable in the gait of a 
person walking slowly away from the observer. 

Fig. 2 n. 





a, rise and fall and onward movement of head. 



Fig. 2 b. 



^■■■■■■■■■■■■■Hil 

■^■■■■[■■[■■■■■■■■Bl 







6, lateral sway of head. 
Fig. 2 c. 




c, rise and fall and forward movement of right hip. 



Fig. 2 d. 




d, lateral sway of hip. 



These curves are best understood by observing (see Fig. 2) the line a, 
which represents the rise and fall and onward movement of the M^hite button 
in the cap worn by the subject, and the line 6, which represents the direction 
and amount of the lateral sway of the same, while the line c represents the 



^'j ■ 



PHYSICAL DEVELOPMENT. 



267 







rise and fall of the riglit anterior superior spinous process of the ilium, 
which is observed to be similar in general course to the line a, but the am- 
plitude of the wave is greatly 

increased. The spinous process Fig. 2 e. Fig. 2/. 

has been selected in preference to 
the pubis employed by Marey, as 
being more definite. Of greater 
interest still is the line e, which 
represents the rise and fall and 
forward movement of the exter- 
nal malleolus of the left foot. 
Tliis curve really consists of a 
number of elements, as elaborated 
by Dercum, in whose own words 
it is best given : " The curve 
begins, e, by the malleolus sweep- 
ing upward on an arc the radius 
of which centres in the ball of 
the great toe. At the next in- 
stant the centre of rotation is 
transferred to the tip of the great 
toe. The balance of the curve 
up to its highest point is the re- 
sult of the flexion of the leg and 
of the forward movement of the 
jjelvis ; thence to the final im- 
pact of the heel upon the ground 
the curve is the resultant of a 
complex movement, in which 
three principal elements are dis- 
tinguishable : first, a pendulum 
movement ; second, a fall ; and, 
tliird, a forward movement, the 
latter being due to the move- 
ment forward of the body as a 
whole. The first two elements 
are those of a cycloid, and the 
foot therefore falls to the ground, 
other things being equal, along 
the line of swiftest descent. 

"A fourth element is ob- 
served in the slight secondary 
rise occurring in the curve just 

previous to its termination. The significance of this 
We notice that the heel of the passive leg in swinging 



■■I 



rise and fall of left foot. 



/, lateral sway of 
left foot. 



rise is as follows, 
forward in its 



268 PHYSICAL, DEVELOPMENT. 

cycloid-like descent does not immediately strike the ground, but that just 
previous to the impact it again makes a slight ascent. This is shown not 
only in the curve, but also in all the plates illustrating the normal walk." 

From a careful study also of the lateral sway of the foot, /, its extent 
was found to be much less than was expected, and, being the least possible 
with the working of the limb, shows a conservation of energy. It is thus 
found in the normal walk, taking all the trajectories together, that the three 
movements forw^ard, laterally, and vertically are correlated, and that the 
greatest economy of force and time results when the secondary (lateral and 
vertical) movements are reduced to a minimum. This conclusion is still 
further strengthened by observing the advent of fatigue in ordinary march- 
ing and when particular methods of marching, demanding increased vertical 
or lateral movements, are attempted.^ 

In slow walking there is a period when both feet are on the ground 
together, a circumstance which does not exist in fast walking, in which one 
foot leaves the ground the moment the other touches it, which accounts for 
the fact that slow walking fatigues more quickly than rapid walking. The 
length of the step depends upon the length of the swinging leg, though this 
may be diminished or increased by direct muscular effort, as when soldiers 
of unequal height keep step, — a mode of marching obviously fatiguing and 
involving an unnecessary expenditure of energy. 

Running. — The short interval described in slow walking when both 
feet touch the earth at the same time is in running replaced by an interval 
when both feet are off the ground at the same moment. To prevent the 
body from falling during this interval, a quick short leap, or kind of jerk, 
is given to the body by quickly flexing the active leg at the commencement 
of the step and forcibly extending it. The duration of the pressure of 
the feet upon the ground is less than in walking, this being proportioned to 
the energy with which the feet tread. These two elements which charac- 
terize running — force and brevity of pressure — increase generally with the 
speed, as does also their frequency, though the extent of space travelled 
may depend upon the extent of each fall rather than upon their number, as 
in some forms of running. 

From the vertical trajectories furnished by the graphic method of 
Marey, he believed that the suspension of the body at each impulse of the 
feet was not effected by a quick leap, as is generally supposed. These 
show that the body executes each of its vertical elevations during the down- 
ward pressure of the foot, and begins to rise as the foot touches the ground, 
" attains its maximum elevation at the middle of the pressure of the foot, 
and begins to descend again in order to reach its minimum at the moment 
when one foot has just risen, and before the other has reached the ground." 
From the relation of the vertical oscillations to the pressure of the feet, he 
plainly shows that the time of suspension does not depend on the fact that 

1 See Eussian Imperial Guards' March, Park's Hygiene, p. 392. 



'*&. 



PHYSICAL DEVELOPMENT. 269 

the body, projected into the air, has left the ground, but that the legs have 
withdrawn from the ground by the effect of their flexion, which takes place 
at the moment when the body is at its greatest elevation. (See Photos. II. and 
III., Running.) 

Fig. 3 represents the rise and fall and onward movement of the right 
malleolus of the first running boy. The curve is similar in its general 

Fig. 3. 




Rise and fall and onward movement of right foot of first running boy. 

course to the line c in Avalking, except that its amplitude is much less, 
showing that the upward movement is more quickly accomplished than in 
walking. Its comparative height is also greater. Compared with line c, 
it displays clearly the difference between these two modes of progression. 
The slight rise just before the completion of the movement has been added : 
this rise, on account of its great rapidity, is lost in running ; but it is 
always present in all slower movements, as in walking. It is found, like- 
wise, in the motion of the horse. 

The muscles concerned in running are those described under Walking, 
the action being more severe and extensive. 

Rowing. — Rowing is one of those exercises which call into play almost 
all the muscles of the body, those of the trunk, as well as those of both 
the lower and the upper extremities. In sitting upright the body rests upon 
the tubera ischii, upon which, as pivots, it swings backward and forward. 
The handle of the oar being grasped by both hands, the first action is a 
compound one, involving first the movement of the trunk or body, and 
secondly that of the entire upper extremity on the trunk : the body is swung 
forward to an angle of forty -five degrees, and the arms are fully extended. 
The second action consists in the recovery of the trunk simultaneously with 
the retraction of the shoulder and the flexion of the arm, supplementary to 
whicjh, by a rapid extension of the wrist by the three extensors of the thumb, 
feathering is accomplished. Simultaneously with the commencement of the 
forward swing the abdominal muscles contract, and the body is drawn forward 
by the psoas and iliac muscles, supplemented by the sartorius and tensor 
vaginae femoris. The extension of the arms to their fullest length is accom- 
plished by the combined action of the serratus magnus and pectoralis minor, 
the triceps and anconeus. The oar is now lowered into the water and the 
boat is propelled by the retraction of the scapulae or shoulders by the tra- 
pezius, latissimus dorsi, and rhomboidei, aided in some degree by the pecto- 
ralis major, the drawing backward of the entire trunk from the angle of 
forty-five degrees to the upright (ninety degrees) by the powerful glutei 
muscles, and the flexion of the arm at the elbow by the triceps and the bra- 
chialis anticus. It will be observed in this description that but little action 



270 



PHYSICAL DEVELOPMENT. 



is attributed to the erector spinse and other muscles of the back: these 
appear simply to render the spinal column inflexible, as their greatest range 
of action cannot exceed from one to two inches. 

The important action of the muscles of the lower extremity as adju- 
vants in good rowing is exhibited in the following manner. In the forward 
swing the extensor quadriceps and leg flexors are slightly relaxed and the 
knees bend a little outward. Then follows the contraction of the biceps, 
semi-tendinosus, semi-membranosus, gracilis, and sartorius, and, later, at the 
commencement of the recovery, in conjunction with the glutei, first the 
quadriceps and then all the muscles of the thigh and leg are powerfully 
contracted, fixing the foot and leg firmly against the " stretcher" and pro- 
viding a fulcrum upon which the powerful glutei can act. A considerable 
number of small muscles of minor importance are also continuously brought 
into play. (See Photo. IV.) From this brief sketch it will be observed that 
the muscles of the hips, of the thighs and legs, of the lumbar region, of 
the upper and dorsal region of the chest, of the arm and forearm, and of 
the interior pectoral region, are all exercised in rowing, their importance 
being in the order named. 

The first trajectory of rowing (Fig. 4) represents the rise and fall of the 
top of the head. It commences just as the body is thi'own farthest forward, 

Fig. 4. 



Rise and fall of head in rowing. 

and gradually rises until in number five, when the arms are fully extended 
and the greatest force is being exerted, the highest point is reached. It is 
lowered slightly during the next three figures, when the final effort is made, 
and is again elevated as the recovery is eflected during the forward move-> 
ment, reaching the low initiatory point again. 



Fig. 




Rise and fall of hand in rowing 



The second trajectory of rowing (Fig. 5) represents the rise and fall of 
the first knuckle on the left hand. 

This corresponds in some respects to the former, but the amplitude of 
the curve is greater, and in the second portion of the curve the same down- 



PHYSICAL DEVELOPMENT. 271 

ward curve is observed, due to the lowering of the body. This was at first 
thought to be due to the position of the hand in feathering ; but this move- 
ment is accomplished during the last two and first two figures. 

Swimming. — Swimming is an act unnatural to man, to learn which he 
must serve a longer or shorter apprenticeship to a new form of locomotion 
and acquire a new order of movements. The human body is lighter than 
water, and the difficulty first experienced in keeping the body afloat is 
usually referable to nervous agitation, and to spasmodic and ill-directed 
efforts of the extremities. Most quadrupeds can swim the first time they 
are immersed, not only because they are lighter than water, but also because 
the movements of locomotion employed by them in their horizontal position 
are precisely those required in swimming. Man, likewise, must assume the 
horizontal position upon the water, either upon the dorsal, vertical, or lateral 
surfaces of the body. In this position the extremities can be employed to 
the best advantage, and the body may be propelled in any direction. 

The position most commonly employed in sv/imming is the prone one, 
with the vertical surface directed towards the water, and the head and 
shoulders and upper part of the back kept up by the trapezius, rhomboidei, 
levator scapulae, serratus posticus superior et inferior, multifidus spinae, etc. 

The upper and lower extremities are simultaneously and slowly flexed 
and drawn towards the body, after which they are simultaneously and rap- 
idly extended and directed away from the body, these movements closely 
resembling those employed by the frog in swimming. These simultaneous 
movements of the extremities describe a series of ellipses, an arrangement 
which, as pointed out by Pettigrew,^ increases markedly the area of support 
furnished by the moving parts. 

In the ellipses the continuous lines represent extension, the dotted lines 
flexion, describing as the extremities are flexed and extended a series of 
ellipses, which as the body advances are opened out and formed into loops, 
and, if a sufficiently high rate of speed be attained, these loops are con- 
verted into waved lines, as in flying or walking. 

The alternate flexion and extension of the limbs decrease and increase 
the angles made by their several parts with each other, thus diminishing 
and augmenting the degree of resistance experienced by the swimming sur- 
faces, and enable the extremities to elude and seize the water by turns. 

Flexion is more slowly performed than extension, and the limbs are 
made to rotate in the direction of their length in such a manner as to 
diminish the resistance during flexion and increase it during extension, thus 
contributing force to the propulsive effort. 

During the extension of the arms the palms of the hands and the inner 
sides of the arms, directed downward, assist in buoying up the anterior 
portion of the body. Towards the end of extension the hands are screwed 
slightly round, and the palms are pronated and directed outward and back- 

^ Pettigrew, Animal Locomotion, etc., p. 81. 



272 PHYSICAL DEVELOPMENT. 

ward, assisting the posterior portions of the arms in the propulsion of the 
body. During flexion the palms of the hands are directed downward, and 
at the close of the movement they are slightly depressed, forcing the body 
upward, and giving to the head the bobbing or vertical wave-movement so 
often observed. 

When the lower extremities are extended, the soles of the feet, the an- 
terior surfaces of the legs, and the posterior surfaces of the thigh, directed 
outward and backward, propel the body forward. This propulsive effort is 
increased by their becoming more or less straight, and by the greater rapidity 
with which the extension is performed. The inner surfaces of the lower 
extremities act upon the water in sustaining the posterior part of the body, 
assisted also by the slightly-inclined position of the body in the water in 
conjunction with the forward movement. 

The flexion of the inferior extremities likewise is performed more slowly 
than the opposite movement. 

Several grave objections urged against the ordinary or old method have 
led to the adoption of new methods. The prone position of the body upon 
the water exposes a large resisting surface; the extremities in the lateral 
position are applied at a disadvantage as propelling agents ; but one-fourth 
of the ellipse is available during the propulsive effort, three-fourths being 
lost, with increasing friction ; and the simultaneous action of both extremi- 
ties leads to dead-points. To overcome these objections scientific swimmers 
have adopted the overhand movement, the method employed by the Indians, 
in which first the arm and leg on one side of the body are moved, and then 
the arm and leg on the opposite side. The direct advantage of this mode 
of swimming consists in the body being thrown more or less on its side at 
each stroke, the body twisting and rolling in the direction of its length, 
thereby reducing the amount of friction experienced in forward motion. In 
the overhand movement the swimmer is enabled to throw his body forward 
on the water and employ his extremities in a nearly vertical instead of a 
horizontal plane, a position best calculated for developing their power and 
reducing friction. The length of the effective stroke is doubled, being 
equal to nearly half an ellipse ; the alternate operation of the sides not only 
contributes to continuity of motion, but also prevents dead-points or halts, 
and reduces friction. For these reasons it is the most expeditious method 
of swimming yet discovered ; but it is so fatiguing that it can be indulged 
in only for short distances. The speed attained by man even by this method 
contrasts very unfavorably with that of seals, and still more unfavorably 
with that of fishes, owing to the small hands and feet possessed by him, 
and to the awkward manner in which they must be applied as propellers. 

For long distances an improvement on the overhand movement is what 
is known as the side-stroke. This consists in swimming upon the side 
of the body ; one arm, say the left, advanced in a curve, describes the 
upper side of an ellipse, while the right arm and both legs by a powerful 
backward stroke propel the body forward. The extension of the lower 



PHYSICAL DEVELOPMENT. 273 

extremities accomplishes a double movement. When extended or pushed 
away from the body, they include within them a fluid wedge with the apex 
directed forward, and when fully extended they are converged in such a 
manner as to force the body away from the wedge and so contribute to the 
propulsive movement. The upper arm may also be extended in such a 
manner as to act as a cut-water, being advanced as the other three extremi- 
ties are flexed, and vice versa. Either side may be employed, or they may 
be alternated. This plan reduces the amount of resistance to the forward 
movement, secures in great measure continuity of movement, and conserves 
the energy and resources of the swimmer to a pre-eminent degree. 

It will be seen from the foregoing account that all the muscles of the 
body are more or less exercised in swimming, but the forward motion is 
accomplished by the extreme force of all the extensors alternately or syn- 
chronously of the upper and lower extremities. 

High Jumping. — The interval described in running when both feet are 
off the ground at the same time is in leaping much prolonged, and during 
this period the body is propelled both forward and upward by a violent 
effort of the extensor muscles (extensor quadriceps) of the thigh, the heels 
being raised by the contraction of the powerful calf muscles (gastrocnemius, 
soleus, jilantaris, flexor lougus, etc.). 

The leap is usually preceded by a short run, to give momentum to the 
body, but the upward movement is accomplished entirely by the lower ex- 
tremities, as above described. In some forms of leaping, particularly the 
standing high jump, much greater heights have been attained by employ- 
ing a peculiar form of jumping copied after that of the cat. In this the 
jump is made sideways, the full force of both lower extremities is secured, 
the body is partially rotated during its flight, and the limbs drawn up are 
carried across the bar together. (See Photo. V.) 

Fig. 6 represents the rise and fall and onward movement of the ex- 
ternal malleolus of the right foot in high jumping. Its general outline 

Fig. 6. 




Rise and fall and onward movement of right foot in high jumping. 

resembles line c in walking, but the amplitude is much greater even than 
this, and it will be especially observed that in the first portion of the curve 
the rise is more quickly accomplished than the descent. The lower curve 
terminates abruptly when the feet reach the ground together. 

By continuing this exercise great skill will be attained, and the exten- 
sors will be wonderfully developed, so that a person can jump easily not 
only to an increased height but also a considerable length, and land in any 
position desired. As an exhibition of skill the length of the run may be 
diminished, or the jump be repeated immediately. A good jumper is a 
Vol. IV.— 18 



274 PHYSICAL DEVELOPMEXT, 

practical example of what may be accomplished by continued exercise of cer- 
tain muscles ; but the most important factor — the development of the chest 
and its contents — has been neglected, and very often such persons suifer from 
consumption or heart-disease because the chest is constantly contracted to 
fix the ribs. True gymnastics are founded upon an anatomical and physi- 
ological law, — that in every position or exercise the full expansion of the 
thorax must be first considered, and the heart must not be over-stimulated. 
Harthelius says that in the Swedish system of gymnastics every movement, 
from the above law, may be looked upon as a respiration movement. 

Varieties of Exercise. — Among the early Greeks the five favorite 
exercises constituting the pentathlon — running, leaping, wrestling, hurling 
the lance, and casting the discus — were admirably adapted to develop the 
body with strength and vigor, and to confer the grace, celerity, and accuracy 
of movement which were so much coveted. These exercises were supple- 
mented by games of ball, lifting and carrying weights, swimming, pugilism, 
and other manly and athletic sports, and revealed the recognition of the 
great principle of variety, there being no such potent cause of fatigue as 
monotonous repetition of the same act, whether physical or mental. 

The tendency of all forms of exercise is to develop some portion of the 
body at the expense of the rest. In walking, running, and rowing, undue 
employment is given to the muscles of the trunk and the lower extremities. 
Indeed, it is difficult to find a variety of exercise that can be sufficiently 
repeated to exercise the muscles of the upper extremity so as to counter- 
balance the excessive development of the lower, or that calls equally into 
action all the muscles of the body. JSTo system of physical education can be 
complete unless it aims at the symmetrical development of the whole body. 

To the natural varieties of games and exercises employed by boys — 
base-ball, foot-ball, cricket, rowing, swimming — should be added systematic 
physical instruction in schools and gymnasiums, directed particularly with a 
view to develop the neglected and weak parts and to add to the symmetry 
of the whole. 

The different varieties of exercises may be enumerated as follows : 
those exercising nearly all the muscles of the body, — climbing, sparring, 
fencing, and swimming ; those exercising both the upper and the lower ex- 
tremities, — foot-ball, rowing, shooting, tennis, rackets, lacrosse, and cricket ; 
and those exercising chiefly the lower extremities, — running, walking, riding, 
dancing, and leaping. 

Effects of Exercise. — The direct effect of exercise — which has 
already been described as a death or burning up of the cellular elements 
of the body — is an increased demand for oxygen to produce this combus- 
tion, which must be supplied through the lungs, thereby producing a 
quickened breathing. The respirations quicken, the pulmonary circula- 
tion is accelerated, the quantity of air inspired and of carbonic acid expired 
is marvellously increased. The increased quantity of air inspired under 
a variety of movements has been carefully investigated by Dr. Edward 



PHYSICAL DEYELOP.^[ENT. 275 

Smith/ with the following result : taking the amount of air inspired in the 
recumbent position as 1, it increases on standing to 1.33, on walking one 
mile per hour to 1.9, on walking six miles per hour to 7, on riding or 
trotting to 4.05, and on swimming to 4.33. 

Not only are the respiratory efforts deepened with exercise, but the 
frequency of the alternate acts of expansion and contraction of the chest is 
directly increased. For example, the adult healthy average, being 14-18 
per minute, would be increased iu Avalking rapidly to 25, in running to 36, 
and in rowing at racing speed to over 40 respirations per minute. At 
the same time the amount of carbonic acid eliminated is relatively lessened ; 
thus, with twelve respirations per minute it is 4.2 ; with twenty-four, 3.3 ; 
with forty-eight, 2.9, — the absolute quantity, however, being increased. 

To supply this increased demand for oxygen, the speed with which the 
blood circulates through the body must be accelerated. By a more rapid 
and forcible impulse of the heart, a larger quantity of blood is sent through 
the lungs and larger supplies of oxygen are taken in and carried to the 
various tissues of the body. In other Avords, exercise not only quickens 
the breathing, but also increases the rapidity and force of the heart's action. 
To make a similar comparison, Bryan Robinson has shown that the pulse of 
a man in the recumbent position, being 64 to the minute, was increased to 78 
during a slow walk, and still further increased to 100 by walking a league 
and a half in an hour, and rose as high as 140 to 150 after running as 
rapidly as possible. It has also been shown by the experiments of Guy ^ 
that the increase from 66 in a man lying down to 71 on sitting up, and to 
81 on standing, was entirely dependent upon the quantity of muscular force 
put forth in maintaining the equilibrium in each of these positions. When 
men have gone through a good deal of exertion and then are called upon 
to make a sudden effort. Park ^ has known the pulse to become very small 
and quick (160-170), but still retain its equability, and without any harm 
resulting. Something similar may be experienced, even by men in excellent 
condition, at the beginning of sudden or violent efforts, as in a foot- or boat- 
race, but as soon as the reciprocal action between the heart and the lungs is 
re-established the individual is said to have acquired his " second wind," 
and may continue the effort to the point of great fatigue. As long as this re- 
ciprocal action between the heart and the lungs is maintained, the interchange 
of oxygen and carbonic acid takes place with sufficient rajjidity ; but when 
this fails, the absorption of oxygen diminishes, carbonic acid accumulates in 
the blood, producing " breathlessness," or loss of wind," or, in other words, 
" blockage" has occurred. This condition is produced by three agencies, — 
interference with the passage of the blood through the lungs, its accumu- 
lation in the right auricle and ventricle, and the circulation of carbonic- 
acid-laden blood through the system. When exercise is regularly taken, 

^ A Treatise on the Animal Economy, p. 177, Dublin, 1732. 
^ Cyclopfedia of Anatomy and Physiology, vol. iv. p. 188. 
3 Op. cit., p. 376. 



276 PHYSICAL DEVELOPMENT. 

the arteries accommodate themselves to the strong action of the heart, and 
a gradual improvement in the breathing-power occurs, with the establish- 
ment of the concordant action between the heart and the blood-vessels. 

The phenomena of increased breathing-power and increased heart- 
action are not without their beneficial influence upon the other parts of the 
body, for exercise includes all the conditions requisite to increased health 
and strength. At the commencement of an exercise the contraction of the 
voluntary muscles put into action comjjresses the blood-vessels and impels 
the venous blood actively towards the heart, which, thus stimulated, con- 
tracts vigorously and propels the blood in increased quantity to the lungs. 
Stimulated by the presence of a large amount of venous blood, the inspira- 
tory muscles contract, and elevate the osseous structure of the chest, the dia- 
phragm pushes down the abdominal contents, and air rushes in to fill the 
cavity thus produced and supply the oxygen demanded for the purification 
of the blood. Laden with this life-giving element, it is returned to the 
heart, to be distributed again throughout the system to restore the loss in- 
curred through the original muscular movement. In this manner not only 
are the voluntary muscles enlarged and strengthened, but the involuntary 
muscles, particularly the heart and diaphragm, im})rove in power and func- 
tion. The increased activity of the circulation carries the blood in increased 
quantity and with greater rapidity not only to the muscles but also to all 
the other tissues and organs of the body, stimulating them to increased ac- 
tivity. The skin becomes red from turgescence of the vessels, the amount 
of perspiration is more than doubled, water, chloride of sodium, and alka- 
line sudorates pass oif in great abundance, and fatty acids, urea, and other 
salts in smaller quantities. The appetite is largely increased, digestion is 
more perfect, absorption is more rapid, hepatic circulation increases, the 
abdominal circulation is carried on more vigorously, and the faeces are 
lessened in amount, probably from the lessened passage of water into the 
intestines. Owing to the increased elimination of water and sodium chlo- 
ride by the perspiration, the amount of these two elements in the urine 
often lessens ; the uric acid, pigment, and free carbonic acid are increased ; 
the sulphuric acid is moderately increased, and the urea and phosphoric 
acid are but little changed. 

It has been supposed that puberty is delayed by physical exertion ; but, 
be this as it may, it is established that very strong exercise lessens sexual 
desire, possibly because nervous energy is turned in a special direction, but 
doubtless also through augmented moral power, the association between 
physical, intellectual, and moral strength being a natural one, unchangeable 
in its essential principles, though subject to individual exception. The 
beneficial effect upon the nervous system is equally striking. It has been 
supposed that excessive exercise renders the intellect less active, owing to 
the greater expenditure of nervous force in that direction ; but not only is 
great bodily exercise quite consistent with extreme mental activity, but, con- 
sidering the principle inculcated in the oft-repeated line from Juvenal of 



PHYSICAL DEVELOPMENT. 277 

mens sana in corpore sano, we must infer that sufficient exercise is necessary 
for the perfect performance of mental work. From the stand-point of a 
comparative physiologist, Du Bois-K-eymond demonstrated that the most; 
marked influence of physical exercise is upon the nerve-centres. In every 
bodily movement of a composite nature, as fencing, swimming, sparring, or 
high jumping, the gray centres of the brain and cord are at work equally 
in securing the result, and are exercised at the same time. 

So closely are the mind and the body correlated that it is hard ofttimes 
to distinguish what is due to the mind and what to the body. In very 
early childhood, with the dawn of mental and physical development, this 
is particularly noticeable, and Prof. Richards, of Yale University, under 
the title of " Body Brain Work," has described it as antedating the advent 
of brain-growth. Every time a child co-ordinates a well-directed move- 
ment, that movement exercises and develops its brain, and the movement 
of the muscles is as necessary to the mental development as the health and 
integrity of the brain are to the physical development of its parts. 

The muscles and the brain are developed by reciprocal action, and in 
later life a direct relation is found to exist between great physical strength 
and the possession of those intellectual powers which naturally lead men to 
commanding positions of authority. Ancient, mediaeval, and modern his- 
tory alike contain numerous instances to prove the accuracy of this state- 
ment. "Samson, though he seems to have lacked discretion, was a judge 
in Israel. Pompey was the ec[ual of any soldier in his command in feats 
of strength. Sallust says of him, ' Cum alacribus saltu, cum velocibus 
cursu, cum validis vecte certabat.' Csesar was naturally of a delicate con- 
stitution, suffisring from severe headaches, and probably epileptic, but by 
continual exercise became an athlete, ' admirable in all manly sports,' and 
surpassed by none in enduring the fatigues and hardships of a military 
life. Lycurgus not only laid down the laws which for fiv^e hundred years 
made Lacedseraon the chief city of Greece, but was able to outrun all the 
mob who persecuted him and forced him to seek refuge in a sanctuary. 
Cicero is described by Plutarch as at one time thin, weak, and dyspeptic, 
but as having been so strengthened by gymnastic exercises at Athens as to 
become robust and vigorous. Coriolanus's successes were attributed by 
his enemies to his strength of body, he having so exercised and inured 
himself to all sorts of activity that he ' combined the lightness of a racer 
with an extraordinary weight in close seizures and wrestlings.' Alcibiades, 
according to Herodotus, became master of the Athenians, in spite of his 
excesses, by reason of his ' force of eloquence, grace of person, and strength 
of body,' and from the same authority we learn that Alexander had unusual 
endurance. Themistocles, Socrates, and Plato excelled in gymnastic exer- 
cises ; Sertorius swam the Rhone in full armor ; Marcellus was ' of a strong- 
body ;' Pelopidas 'delighted in exercise;' Marius never missed a day on 
the Campus Martins; Cato 'maintained his character and persisted in his 
exercise to the very last ;' and even the more mythological characters of 



278 PHYSICAL DEVELOPMEXT. 

Theseus, Romulus, and Remus are accredited with ' strength of body and 
bravery equal to the quickness and force of their understanding.' "^ 

In the " University Oars" Dr. Morgan calls attention to the fact that 
of the one hundred and forty-seven Cambridge men who constituted the 
crews from 1829 to 1869, twenty-eight per cent, won honors in more im- 
portant contests than those upon the river, securing in some instances the 
very highest academical distinction, and proving that mind and muscle, judi- 
ciously guided, are well able to work together with reciprocal advantage. 

Sargent has pointed out that college men take about the same grade in 
their general studies as in required athletics,^ and Dr. Morgan has shown 
that, while the general average of class men at Oxford was about thirty 
per cent., among cricketers it rose to forty-two per cent, and among rowing 
men to forty-five per cent. 

In a recent investigation by a prominent American physician to show 
the comparative longevity of brain-workers as compared with muscle- 
workers, the advantage was clearly shown to be in favor of the former. 
This might have been expected a jwiori in view of the classes from which 
these so-called " muscle-workers" are naturally derived, who through poverty 
are forced all their lives to live under the most unsanitary conditions, who 
neglect from ignorance and powerlessness the most obvious laws of health, 
and who in all respects labor under a stupendous physical disadvantage 
when brought into comparison with the so-called " brain-workers." Their 
work is not exercise ; it is fatiguing labor, performed ofttimes under the 
most depressing intellectual conditions. 

On the contrary, it is not difficult to prove that a sound constitution 
usually accompanies a healthy brain, and that the cerebral and the muscular 
forces are directly correlated. In this connection. Dr. Beard declared that 
in all the animal realm there is a general, though not unvarying, relationship 
existing between the brain and the body, and that no one who has ever 
walked observingly through an asylum for the insane or feeble-minded and 
beheld the dwarfed, misshapen, immature, or stunted forms which surround 
liim can doubt the force of the truth embodied in this statement. He points 
out the rapidity with which such poor creatures grow physiologically old, the 
evidences of senility noticeable in every organ and function, — in the gray 
hair and premature baldness, in the dimness of vision and dulness of hear- 
ing, in the wrinlvled skin, the tottering step, the wasted limbs. Conversely, 
he maintains that one hundred great geniuses chosen by chance will be taller, 
broader, and weightier than a hundred dunces anywhere, and declares that 
in all lands, savage, semi-civilized, and enlightened, the ruling orders, 
chiefs, sheiks, princes by might and mind, authors, scientists, orators, great 

^ White, Lippincott's Monthly Magazine, June, 1887, p. 1013. 

^ " In this connection it is worthy of mention that the most athletic seniors in the classes 
of 1885-86 and 1886-87 (Harvard) included one honor man who received honors, nine who 
received honorable mention, and twelve who were entitled to write commencement parts." 
— Report upon Athletics, etc., Cambridge, 1888, p. 22. 



PHYSICAL DEVELOPMENT. 279 

merchants, weigh more on the average than the persons wliom they rule or 
employ, and that even among a band of workmen on a railway one can four 
times out of five select the '' boss" by liis stature alone ; and Bates tells us 
that among the people of the Tapajos the footmarks of the chief could be 
distinguished from the rest by their great size and by the length of the 
stride. On the same principle Herbert Spencer has shown how in early 
times among rude tribes political leadership was associated, as in the present 
times, with physical strength. 

In early Greece the veneration of age did not recompense for loss of 
strength, and an old chief, like Laertes or Peleus, had to relinquish his 
position. Throughout mediaeval Europe the maintenance of political leader- 
ship depended largely on bodily vigor. Supremacy among the Australians 
and Tasmanians depended upon physical size and strength. The Esqui- 
maux exhibit deference to " seniors and strong men ;" amouo- the Bushmen 
" bodily strength alone procures distinction ;" and " the fiercest, the strongest, 
and the craftiest" among the Bedouins " obtains a complete mastery oyer 
his fellows." 

The direct influence of exercise upon longevity has been curiously 
brought out in a list prepared not to show the average longevity, but to 
determine the age when great men have performed their best work : the 
average age at death was sixty-four. Likewise Madden, in his odd book 
upon " The Infirmities of Genius," in a list of two hundred and forty illus- 
trious men, found the average age at death to be sixty-six, proving that 
many of the great men of the past have been noted for physical strength 
as well as for intellectual greatness, and that the attention given by them 
to physical development had been productive of both great mental ability 
and increased tenure of life. Personal examples from anwng the distin- 
guished men of the present century, justifying this statement, might be 
produced indefinitely. 

These, then, are the physiological effects of exercise, — an increase of the 
voluntary muscles in volume and power, an enlarged respiration and quick- 
ened circulation, through a strengthening of the involuntary muscles con- 
cerned in these processes, and an improved action of all the functions and 
faculties concerned in the growth and development of the whole body, the 
force and activity of the intellectual and moral processes, and the longevity 
of the individual. 

While the beneficial effects of exercise are so great and so important, 
the fact must not be overlooked that it is also capable of great abuse. 
When unaccustomed exercise is engaged in after a long interval of rest, 
" blockage" occurs not only of the arteries going to the lungs, but also of 
those supplying the whole body, particularly when violent exercise is under- 
taken without due preparation, as when a tired, delicate, or overworked man, 
for months engaged in a sedentary, literary, professional, or mercantile pur- 
suit, or a tender untrained student, suddenly indulges in some active or 
violent form of gymnastics, or engages in one of the recreative sports which 



280 PHYSICAL DEYELOPMEXT. 

make the greatest demand upon the heart and lungs, as boating or running : 
instead of a beneficial result accruing, serious and often permanent injury 
frequently follows. Such important involuntary organs as the heart and 
lungs cannot instantly pass from the quiescent state of ordinary life move- 
ments to great rapidity of action without strain being thrown upon them, and, 
instead of the vital action being quickened and the processes of repair and 
removal stimulated, the blood is blocked in the arteries, the cavities of the 
heart are over-distended, and dilatation or hypertrophy speedily results. To 
avoid this should be regarded as of vital importance in all forms of exercise, 
but especially in training should it be borne in mind that the chief object is 
" to establish a reciprocal action between the heart and the lungs, so that the 
increased supply of blood sent to the lungs by the heart may pass through 
them freely, so that there may be no blockage and consequently no strain." 

It must also be recollected that the development of the voluntary 
muscles gives no indication whatever of the condition of the involuntary 
muscles involved in maintaining the respiration and circulation, and that an 
enormous muscular development may be absolutely useless without the cul- 
tivation of the heart and lungs, a circumstance pointed out by Maclaren to 
explain the result of the celebrated Heenan-King prize-fight. 

Exhaustion of muscles from overwork is chiefly owing to the exhaustion 
of the supply of oxygen, and to the accumulation in them of the products 
of their own metamorphosis, especially paralactic acid. This is the result 
of the eifect of general fatigue upon the nervous system, the heart, and the 
circulation of the blood. Hence rest is demanded in order to allow the 
removal of waste products from the tissues, to restore their alkalinity, and to 
acquire a sufficient quantity of oxygen. Thus, in the heart the interval 
between the contractions (about two-thirds of the time) is sufficient to allow 
the muscular structure perfectly to recover itself. Muscles that have under- 
gone exhaustion have nutrition seriously impaired, as manifested by the so- 
called "acute local fatigue," not simply in loss of power, but often in 
iiTegular, painful muscular contractions, cramp, tremor, and peculiar, dis- 
tinguishable muscular pain. 

To avoid the results of these spasmodic efforts, children and youth 
should not be allowed to undertake any form of exercise calling for sudden 
or violent exertion until a certain age is passed, and certainly not without 
having been examined by the regular medical attendant before, or by the 
medical director upon, their entrance to the school or college gymnasium, 
to ascertain the condition of the heart and lungs, the general muscular de- 
velopment, and the existence of any hereditary taint. This would not con- 
flict with the physical examination, to which full reference will be made 
under the subject of physical education, but w^ould be preliminary and 
supplemental to the more thorough examination of this kind made to 
ascertain the development. 

The evil effects resulting from the lack of perfect exercise are not so 
evident in the period of life under consideration as in later life, when the 



PHYSICAL DEVELOPMENT. 281 

more active sports of youth are replaced by the sedentary pursuits aud 
the enervating influences of a business life. 

Exercise in Infancy and Childhood. — The natural movements of 
an infant are the apparently purposeless muscular efforts which it makes as 
soon as it appreciates that it has extremities. " A child in health delights 
in movements of all kinds," says Sir William Jenuer. '^ It joys to exercise 
every muscle. Strip a child a few months old, and see how it throws 
its limbs in every direction ; it will raise its head from the place on which it 
lies, coil itself round, aud grasping a foot with both hands thrust it into its 
mouth as far as possible, as though the great object of its existence at that 
moment was to turn itself inside out." These movements are its natural 
exercise, developing the muscles and brain correlatively, as already pointed 
out. For this reason its limbs should not be too much compressed or 
weighted down with heavy clothing, and it should be encouraged to roll 
about aud exercise itself as much as possible. Its first attempts at com- 
bined movements, to crawl on all-fours, quadruped-like, are soon followed 
by attempts to assume the upright position by the support of some object, 
and endeavor to balance the upper part of its body, which at this time is 
developed far beyond the lower extremities. Sunlight and fresh air are at 
this time very necessary to add firmness and strength to the whole structure, 
and with the exercise of its limbs the upright position is soon acquired, aud 
the child has gradually taught itself to walk. 

These first efforts should be encouraged, but should not be too pro- 
longed, lest injury result. As time advances, and the child becomes more 
and more independent of support, the constant activity and impatience 
exhibit plainly the intentions of nature, aud after the child is three years 
old a degree of activity may be imparted by encouraging it to run with 
a ball, play with a small dog, or, later, exercise with a hoop. In this 
manner from a very early age exercise may be begun aud be encouraged, a 
rocking-horse may be added to the nursery, later the careful use of a veloci- 
pede or tricycle may be employed in the open air, to be still further substi- 
tuted, as the child advances, by the use of roller-skates and the exchange 
of the rocking-horse for the pony. In all these forms of exercise great 
care should be observed that the saddles be not too wide, lest deformity 
result. It is also to be distinctly understood that these are to be employed 
with the greatest caution ; and if the child have hernia they should not be 
employed under any circumstances. At the end of the fifth year children 
may spend an hour or two in the kindergarten, but regular schooling 
should not be commenced till the end of the seventh year, and during the 
later period of childhood sufficient time should always be allowed for plenty 
of play and exercise in the open air, regard being had to the state of the 
weather. Thus, many children have fallen victims to pneumonia, bron- 
chitis, and croup from having run or walked against a piercing easterly 
wind, long walks and violent play through overfatigue and cold have led to 
hip-joint aud knee disease, and drinking cold water when overheated, or 



282 PHYSICAL DEVELOPMEXT. 

sitting upon damp ground or stones, has produced irretrievable injury in 
many others. The younger and more delicate the child, the more care has 
to be exercised in regard to the state of the weather. If born in tlie latter 
part of autumn, infants cannot with safety be taken out before the return 
of spring ; but if the apartments are large and airy, little evil will result 
from this prolonged confinement. AVith the return of mild, dry, and serene 
weather, they must be carried out into the open air, and, should the weather 
permit, this salutary practice must be daily repeated. In fine weather chil- 
dren and youth may spend the greater part of the day out of doors, and as 
they grow in years they become gradually accustomed to the vicissitudes of 
a changeable climate. In large cities, large open spaces, parks, and gardens 
should be frequented, and in the summer months the overheated and over- 
crowded cities should, if possible, be exchanged for the country and sea-coast. 

From five to twelve, boys and girls alike may engage in any of the light 
active games which do not throw weight or strain upon the growing joints, 
avoiding wrestling, foot-ball, and premature attempts at rowing. 

In early boyhood and youth nothing can replace the active sports so 
much enjoyed at this period, and, while no needless restriction should be 
placed upon them, consideration should be paid to the amount and especially 
to the character of games pursued by delicate youth. For these it would be 
better to develop the weakened parts by means of systematic gymnastic 
exercises, by short excursions into the country, and by the lighter sports. 

It should be borne in mind that in order to obtain the greatest advan- 
tage from those exercises which are calculated to improve the physical and 
nervous strength the child should be interested and made to feel that these 
exercises are a play instead of a task. 

Children who are taught at an early age to be obedient seem to enjoy 
more thoroughly such exercises as combine discipline with rhythmic move- 
ments ; and, consequently, the older the child the more important it is to 
adopt a system of calisthenics, or light drill, or games that combine gym- 
nastics with rhythmic sounds and periods of rest. 

The more permanent benefits of play (games) are promptness, attention, 
fast and easy running, climbing, balancing, strength, endurance, marksman- 
ship, elasticity, etc. These games may be classified as follows : 

1st. Exercises which in some respects stand in the line between free 
games and gymnastics, since they retain some school discipline and are 
played systematically under the direction of the teacher. These are of 
varied character, some more suitable for older, others for younger chil- 
dren (racing, " prisoner's base," etc.), the difference between these games 
and gymnastics being often not easily distinguishable. For young men 
the best of these is fencing. 

2d. Exercises which also have some value in a gymnastic sense, but 
which are not to be played in classes or under the command of the teacher. 
These are called free gymnastic games, from the fact that the teacher can 
take part, if so disposed, but need not do so. To a great many free games 



PHYSICAL DEVELOPMENT. 



283 



belong certain words, declamations, or the singing of different melodies. 
If the instructor in gymnastics for children take up dancing, the principal 
object should be to give the children the greatest possible liberty, and not 
to attempt to obtain perfect grace and form-beauty. 

3d. The third and last class of plays (games) includes games of no 
gymnastic value. To this class belong all sitting, forfeit games. These 
are as useless as the great number of meaningless movements which have 
been introduced into gymnastics, many of which are only methods without 
gymnastics, which is as incorrect as gymnastics without method. 

The Development of Boys ^ has attracted considerable attention of 
late years, but the systematic records are as yet insufficient to admit of any 
dogmatic deductions. For older children ihe records of college gymnasiums 
are available to show the rapid increase which systematic exercise causes in 
the physical development. We have, however, the very valuable papers 
of Mr. Street, F.R.C.S., Mr. Roberts, F.R.C.S., and Dr. Bowditch. 

Mr. Street's observations are based upon the examination of three thou- 
sand six hundred and ninety-five boys, drawn chiefly from the artisan class, 
varying from thirteen to nineteen years, and are interesting as exhibiting 
the height, weight, etc., for the five years inclusive. 

TABLE 



Showing the Relation of Weight to Height of Boys between the Ages of TIdrteen and 

Nineteen Yeai's.- 



Height 

WITHOUT Shoes, 

IN Inches. 


Weight in Pounds, without Coat, Hat, and Shoes. 


Average 
Weight 

IN 

Pounds. 


Age Last Birthday. 


Thirteen. 


Fourteen. 


Fifteen. 


Sixteen. 


Seven- 
teen. 


Eighteen. 


Nineteen. 


71 

70 

69 

68 

67 

66 

65 

64 

63 

62 

61 

60 

59 

58 

57 

56 

55 

54 

53 

52 

51 


ill 

103 
96 
96 
90 
87 
86 
82 
78 
75 
74 
72 
73 
62 


129 

i23 
119 
107 
112 
108 
101 

98 

93 

89 

86 

83 

80 

76 

74 

69 

70 

1 


136 
142 
131 
120 

117 

117 

115 

108 

104 

99 

92 

91 

87 

83 

78 

77 

74 


144 

132 

126 

125 

122 

115 

115 

110 

106 

101 

96 

93 

88 

86 

87 

76 

67 

67 


14 
14 
13 
13 
13 
12 
12 
11 
11 
10 
10 
10 
9 
9 

's 


9 
7 
8 
1 
2 
6 

6 
5 
9 
8 
1 

i 


129 
151 
144 
142 
129 
126 
127 
115 
117 
111 
102 
109 
91 

76 


15 
13 
14 
14 
13 
13 
12 
12 
11 
11 
10 



7 
D 
4 
8 
[) 
1 
[) 
7 
3 
9 


142.6 
143.0 
139.4 
134.8 
128.0 
123.3 
118.0 
115.0 
111.1 
105.7 
103.0 

97 

90.7 

82.2 

83.5 

80.8 

76.0 

72.2 

70.5 

70.0 

62.0 

1 



1 Koberts, The Phj^sical Development ttud Proportions of the Human Body. ^ Street. 



284 



PHYSICAL DEVELOPMENT, 



Starting with au average height of fifty-five inches at thirteen years, 
these figures show an increase of one inch during the first year, of three 
inches during the second year, of four inches during the third year, and of 
one inch each during the fourth and the fifth year, whilst from nineteen to 
twenty there is scarcely any increase in stature. From Mr. Roberts's table 
the increase for each year from thirteen to sixteen is over two inches, being 
greatest during the sixteenth year ; during the seventeenth year it is about 
one and one-half inches (1.53); from seventeen to eighteen it is about one 
and three-fourths inches, dropping during the next year to less than one 
inch (0.68), and during the year from nineteen to twenty to less than one- 
half inch (0.43). 

TABLE 

Showing the Average Proportion and Growth of the Human Body from Birth to Maturity} 











Average Proportions 
OF THE Body (Males). 


ANNa'AL Rate of 
Growth. 


Ratio of Increase. 
Height = Unity. 


Age Last Birth- 




















day. 


Height, 
Inches. 


Chest- 
Girth, 
Inches. 


Weight, 
Pounds. 


Height, 
Indies. 


Chest- 
Girth. 
Inches. 


Weight, 
Pounds. 


Height, 
Inches. 


Chest- 
Girth, 
Inches. 


Weight, 
Pounds. 


Birth 


19.34 


13.25 


7.55 














1 year 








28.50 






9.16' 






- . 






2 years 

3 " 








31.60 
35.00 






3.10 
3.40 












4 " 








38.45 




31.10 


3.45 


. . 










5 " 








41.15 


21.26 


37.71 


2.70 












6 " 








43 18 


21.68 


40.67 


2.03 


42 


2.96 


1 


0.20 


1.45 


7 " 








45.15 


22.25 


44.00 


1.97 


0.57 


3.33 1 


0.28 


1.70 


8 " 








46.92 


22.66 


47.15 


1.77 


0.41 


3.15 1 1 


0.31 


1.80 


9 " 








49.52 


23.27 


51.20 


2.60 


0.61 


4.14 : 1 


6.24 


1.60 


10 " 








51.52 


23.77 


55.50 


2.00 


0.50 


4.21 j 1 


0.25 


2.10 


11 " 








52.87 


24.33 


60.15 


1.35 


0.56 


4.65 1 1 


0.41 


3.44 


12 " 








54.45 


24.81 


64.52 


1.58 


0.48 


4.37 1 1 


0.30 


2.76 


IB " 








56.56 


26.30 


71.00 


2.11 


1.49 


5.48 j 1 


0.70 


2 60 


14 " 








58.55 


28.18 


79.57 


2.00 


1.88 


8.57 


1 


0.94 


4.28 


15 " 








60.77 


29.70 


91.43 


2.21 


1.52 


11.86 




0.68 


5.36 


16 " 








63.42 


31.19 


107.86 


2.65 


1 49 


16.43 




0.56 


6.20 


17 " 








64.95 


82.80 


118.08 


1.53 


1.71 


10.22 




1.10 


6.67 


18 " 








65.69 


34.03 


127.25 


1.74 


1.23 


9.17 




0.70 


5.27 


19 " 








66.37 


34.76 


131.48 


0.68 


0.73 


4.23 




0.10 


6.22 


20 " 








66.80 


35.13 


135.28 


0.43 


0.37 


3.80 




0.08 


0.90 


21 " 








66.80 


35.42 


135.03 




0.29 


1 







According to Dr. Bowditch's tables there is an increase in height from 
the thirteenth to the fourteenth year of over two inches, from the four- 
teenth to the fifteenth of over two inches, from the fifteenth to the sixteenth 
of over two and a half inches, from the sixteenth to the seventeenth of 
nearly one inch, and from the seventeenth to the eighteenth of a little over 
one-half inch, among the non-laboring classes, these figures being slightly 
less among the laboring class. 



' Eoberts, op. cit. 



PHYSIC .VL DEYELOP.MENT. 



285 



TABLE 

Shojv'mr/ Average Heir/Jds and Weights of Boston School-Boys, irrespective of Nationality} 







Occupation 


OF Parents 






^- 


ox-Laboring. 




Laboring. 




Age Last Birthday, 












No. of Ob- 


Height, 


Weight, 


Ko. of Ob- 


Height, 


Weight, 




servations. 


Inches. 


Pounds. 


servations. 


Inches. 


Pounds. 


5 vears 


135 


41.64 


41.21 


694 


41.57 


41.00 


6 '• 


248 


44.11 


45.50 


1007 


43.74 


45.06 


7 " 


294 


46.23 


49.77 


1133 


45.61 


48.93 


8 " ....... 


295 


48.08 


54.64 


1161 


47.67 


53.67 


9 " ....... 


272 


50.03 


59.89 


1097 


49.73 


59.22 


10 " 


262 


52 12 


66.31 


1023 


51.55 


64.89 


11 " 


284 


58.84 


71.81 


956 


53.17 


69.67 


12 " 


277 


55.92 


80.38 


899 


54.84 


75.88 


13 " 


277 


58.13 


88.59 


800 


56.89 


83.40 


14 " 


235 


60.52 


96.54 


582 


59.31 


93.67 


15 " 


231 


62.68 


108.81 


865 


61.90 


104.88 


16 " 


169 


65.28 


122.48 


162 


64.65 


119.03 


17 " 


97 


66.17 ! 128.23 


77 


65.75 


125.28 


18 '■■ 


46 


66.69 132.00 


28 


66.35 


131.60 



We have had some interesting studies made bv Dr. A. A. Eshner at 
the Philadelphia Hospital, which are shown in the following table : 



Name. 



C. M. 
L. H. 
C. H. 
M. L. 
M. B. 
A. OB, 
L. G. 
H. P. 
O'B. . 
J. . . 
A. C. 
G. iS^. 
A. E. 
O'H. . 
J C. . 

w. . 

W. M. 
M. C. 

F. . . 

G. M. 
E. . . 
M. E. 
K. . . 
V. B. 
C. E. 
L. C. 



Age. 



19 

101 

61 

126 

183 

308 

199 

162 

11 

22 

9 

8 

34 

16 

33 

35 

51 

319 

238 

205 

242 

65 

270 

175 

585 

90 



days. 



Height. 



Weight. 



Expansion. 



221 
25| 
28>- 
{251 
! 25J- 
25' 
27} 
261 
18| 
21i 
21 
20f 
20 
2U 
211 
21 
26 
291- 
261 
2bl- 
28' 
281 
28 
241 
27 
20.1 



inclies.' 8.V pounds 
" I 141 '• 
" j 10 
" 1 15 " 
14 

15 " 
17 " 
17 
4 " 
9 
6 
7 



n 



1 ounce. 

1 1 ounces. 

1 ounce. 

2 ounces. 
6 " 

3 " 

12 " 



13 
4^ 
12' 



inch. 

inches. 

inch. 



6 

7 
16 
19 
17 
11 
14 
10.^ 
18.V 
11" 
10 



7 

4 

13.^ 



These measurements represent but a small number of children, and 
they should be carried out to a greater extent. The expansion noted is, of 
course, the ordinary expansion of breathing, and not foi'ce-respiration. 



1 Buwditch. 



286 PHYSICAL DEVELOPMENT. 

From these tables it is evident that the period in a boy's life between 
the sixteenth and the seventeenth year is one of great importance, during 
which no great strain should be thrown upon his developing constitution, 
and that feats of strength or physical endurance should not be undertaken 
until this period is safely passed. 

With his entrance to college the youth has an opportunity of laying the 
foundation of his physical development in a use which will serve him, 
with proper care, through his future life. As a rule, this is what the 
average American student requires, for Prof. Elliott, of Harvard, said of 
the majority entering that institution that they had "undeveloped muscles, 
a bad carriage, an impaired digestion, without skill in out-door games, and 
unable to ride, row, swim, or shoot ;" and what is true of Harvard applies 
with greater force to many other American colleges. With the present sys- 
tems of physical culture in operation in all the important Eastern colleges, 
the freshman on entrance is examined as to his physical condition and 
advised what forms of exercise he requires, and is re-examined from time 
to time to ascertain his progress and advised as to his subsequent course. 

The systems of physical education at present employed in Harvard, the 
University of Pennsylvania, and other American colleges, and copied after 
those long in use in Oxford, are approximately as follows. Each student 
upon his entrance to college is stripped, and measurements are taken of his 
height, weight, circumference and diameter of chest, legs, thighs, arms, and 
forearms, which are recorded in some convenient form (centimetres or 
inches). These together are taken approximately as an indication of his 
development : it shows the amount of working material, but not its actual 
working value. These are followed by a series of tests to ascertain the 
total available strength ; by means of the spirometer, the horizontal bar, 
and the lifting machine, the strength and capacity of the lungs, and the 
relative strength of the arms and chest, back, legs, and thighs, abdominal 
muscles, and forearms, are all estimated. These are recorded in the same 
form as the first, and, representing the development and available strength, 
readily admit of comparison. To these are finally added the personal and 
the family history of the individual. 

The chart employed to record the measurements, etc., is as follows : 

PERSONAL AND FAMILY HISTOPvY. 

Be sure to answer every question; say "yes," "no," or "I don't know," whenever 
possible. 
Name, 

Class and department, or occupation, 
Age, Birthplace, 

Nationality of 

Father, 

Mother, 

Paternal grandfather. 

Paternal grandmother, 

Maternal grandfather, 

Maternal grandmother, 



PHYSICAL DEVELOPMENT. 



287 



Occupation of father, 

If parents are dead, of what did they die ? 

Which of your parents do you most resemble ? 

Is there any hereditary disease in your family ? 

Is your general health good ? 

Have you alwaj-s had good health ? 

Have vou ever had anv of the following diseases? 



Asthma, 

Shortness of Breath, 

Bronchitis, 

Spitting of Blood, 

Pleurisy, 

Pneumonia, 

Palpitation of the Heart, 

Bright's Disease, 



Eheumatism, 

Neuralgia, 

Sleeplessness, 

Headaches, 

Paralysis, 

Dizziness, 

Fits, 

Eupture, 

Have you ever had any injury or undergone any surgical operation? 
What have been your favorite exercises ? 
How much time have you devoted to them daily ? 
How much time do you spend in the open air daily ? 
How many hours do j'ou sleep daily ? 

How much time do you spend in study outside of the college ? 
To what extent do you use tobacco ? 
To what extent do you use alcoholic or malt beverages ? 

Examination of Mk, 
Class. 



Dyspepsia, 

Habitual Constipation, 

Varicose Veins, 

Piles, 

Liver Complaint, 

Jaundice, 

Chronic Diarrhoea, 

Dysenterj\ 





1. 


2. 


3. 


4. 


Date 










He 


e 










ight 








W 


eight 










Girth, Head* 












' Neck 










' Chest, full * 










' " repose* 










' Belly* 










' E. Thigh* 










' L. " * 










' E. Knee 

' L. " 


















' E. Calf 

' L. " 


















' E. Arm* 











' L. " * . 








' E. Forearm* 










' L. " 










Ca 


p. Lungs 










Ex 


pirat. Strengthf 










Strength E. Gripf 

" L. - t 

" Backf 



























" Thighsf 










Di 


n<t 














Ch 
















288 



PHYSICAL DEVELOP.MENT. 



a means above and 6 means below the average 
according to age. 


Condition. 


Develop- 
ment. 


Strength. 


First Examination. 








Average. 








Second Examination. 








Average. 








Third Examination. 








Average. 








Fourth Examination. 








Average. 








Improvement. 









Note.— -Development— The sum of the nine girths marked *. 
Strength — The sum of the seven tests marked t. 

Condition — The difference between development and strength ; if in favor of the former it 
is minus (— ), and if in favor of the latter it is plus (+). 

Willi sitch data before him, the medical examiner is in a position to 
advise the student upon several matters of the greatest importance. He 
can limit or altogether interdict exercise, he can prescribe parallel and 
upright bars for a rachitic chest, he can suggest the rowing-machine or 
exercise upon the river for the student with weak legs, he can advise the 
corpulent individual with flabby muscles to become more active, and he can 
diagnose and prescribe for inherited tendencies and latent diatheses with a 
scientific thoroughness based upon a careful examination and an exact 
knowledge of the individual which few practitioners enjoy. These phys- 
ical examinations are repeated once or twice during the year, and the results 
carefully noted and compared. 

Dr. Sargent recently, in describing the system of physical education in 
use at the Hemenway Gymnasia at Harvard, said,^ — 

" Every student who enters the University is entitled to an examination, 
and eighty-seven per cent, of the whole number avail themselves of this 
privilege. 

"As soon as the student presents himself at the director's office (which 
is done by application and appointment), he is given a history blank, which 
he fills out, giving his birthplace, nativity of parents, occupation of father, 
resemblance to parents, natural heritage, general state of health, and a list 
of the diseases he has had, all of wliich information is absolutely necessary 
in order for the examiner to put a correct interpretation upon the observa- 
tions to follow. The student is then asked to make certain tests of the 
muscular strength of the different parts of his body, and to try the capacity 
of his lungs. 

"He then passes into the measuring-room, and lias his weight, height, 



' Physical Training Conference, 1889, p. Go, 



PHYSICAL DEVELOPMENT. 289 

chest-girth, and fifty other items taken. His heart aud hiugs are then 
examined before and after exercise, aud a careful record made of the con- 
dition of the skin, muscles, spine, etc., which the tape-measure fails to 
give. 

" All tlie items taken are then plotted on a chart, made from several 
thousand measurements, aud the examiner is thus able to know the relative 
standing of this individual as compared with others for every dimension 
taken, also his deviation from symmetry, aud the parts which are in special 
need of development. 

" To confirm the plotting of tlie chart, and to awaken in the young man 
a genuine interest in his physique, a photograph of each student desiring it 
is taken in three positions, and preserved for comparison with those to be 
taken of him later. 

" From the data tlius procured a special order of appropriate exercises 
is max:le out for this student, with specifications as to the movements and 
apparatus he may best use. At the present time this special order consists 
for most students of an illustrated hand-book, in ^vhich the apparatus, the 
weights for it, and the times to use it are carefully prescribed, together with 
such suggestions as to exercise, diet, sleep, bathing, clothing, etc., as will 
bast meet the needs of the individual under consideration. 

"Xow, I think it will be admitted by all thoughtful persons that one- 
half the battle for mental education has been won when you arouse in a 
boy a genuine love for learning. So one-half the struggle for physical 
training has been won when he can be induced to take a genuine interest in 
his bodily condition, — to want to remedy his defects, and to pride himself 
on the purity of his skin, the firmness of his muscles, and the uprightness 
of his figure. 

" Whether the young man chooses afterwaixis to use the gymnasium, to 
run, to row, to play ball, or to saw wood, for the purpose of improving his 
physical condition, mattei's little, provided he accomplishes that object. 

"The modern gymnasium, however, offers facilities for building up the 
body that are not excelled by any other system of exercise. The introduc- 
tion of the new developing appliances has opened up the possibility of the 
gymnasium to thousands to whom it was formerly an institution of doubtful 
value. The student is no longer compelled to compete with others in the 
performance of feats that are distasteful to him. He can now compete with 
himself — that is, with his own ])hysical condition — from week to week, aud 
from month to month. If he is not strong enough to lift his own weight, 
the apparatus can be adjusted to a weight he can lift. If he is weak in the 
chest or the back, he can spend his time and energy in strengtlieuing those 
parts without fear of strain or injury, 

" In fact, he can work for an hour, going from one piece of a]>paratus 

to another, keeping always within the circuit of his capacity, and adding 

slowly and surely to his general strength and powers of endurance. If the 

heart is weak, the lung-capacity small, the liver sluggish, the circulation 

Vol. IV.— 19 



290 PHYSICAL DEVELOPMENT. 

feeble, or the nervous system impaired, etc., special forms of exercise can be 
prescribed to meet these conditions. 

" Gentle running is usually advised as a constitutional exercise for all 
those who can take it. This is usually severe enough to start the per- 
spiration and make a bath of some kind desirable. A tepid sponge- or 
shower-bath is generally advised ; and, in my opinion, the bath which 
regularly follows the exercise at the gymnasium, and the habit of bathing 
established thereby, are almost as valuable as the exercise itself. 

" After a period of six months or more, the student returns again to the 
director's office, and has another examination, in order to ascertain what 
improvement he has made, and to receive any new suggestions. 

" This, in brief, is the educational part of the system of physical training 
carried on at the Hemenway Gymnasium." 

From the accumulated results thus obtained a greater symmetrical de- 
velopment of all the parts is shown, and under this system not only are 
greater feats accomplished, but they are performed with greater ease and 
safety. 

This is well exhibited in the tables^ made out in Harvard aud repre- 
senting the increase in eight years. Whereas 675.2 was the highest num- 
ber of points, according to the standard of the director of the Hemenway 
Gymnasium, gained by any man in college in 1879-80, and 632.2 was the 
average of the ten strongest men in the college in that year, in 1887 there 
were out of 1077 students attending college, 824 of whom were examined, 
94 men with a strength above 675.2, 145 with a strength above 632.2, and 
the men with a strength above mean (of 400 points) reached the high num- 
ber of 609. In the same report there were on record the " names of two 
hundred and forty-five students whose test of general strength (of arms, 
chest, back, legs, lungs, etc.) surpasses the test of the strongest man in 
1880." 

TEAINING. 

The general principles involved in training are often poorly understood, 
even by trainers themselves. 

As Dr. Parkes has expressed it, " training is simply another word for 
healthy and vigorous living," a condition which can be attained only by 
the strictest adherence to a system of diet, the employment of regular and 
systematic exercise, and the most scrupulous attention to the minutiae of 
general aud personal hygiene. By attention to these the body is brought 
into a perfect condition of health, with enlarged and strengthened muscular 
action, improved circulation, and increased breathing-power. 

The most important consideration is time. AVhen we consider the in- 
creased force of the heart, acting rapidly upon a large volume of blood, the 
enlarged calibre of the vessels, the expansion of the chest and of the lungs 
themselves, aud the increased bulk and tone of the muscular system, volun- 

^ Eeport upon Athletics, Htirvard College, 1888, p. 36. 



PHYSICAL DEVELOPMENT. 



291 



tary and involimtaiy, it becomes obvious that a long time is demauded to 
accomplish these residts. 

It is needless here to dwell upon the necessity for general exercise of 
the whole body, or to point out that the exercises should not be limited to 
the particular forms of muscular movement to be finally performed : suffice 
it to say that the work should be alternated, and that long intervals of rest 
should succeed periods of activity. 

In regard to the diet to be employed in training, many of the old ideas 
and rules have of late years been much modified. 

From what has been already stated under calorification, the Avork per- 
formed by the body demands a constant renewal of fuel, and it remains 
to discuss what is best suited to supply the most effective force-value. 

All foods may be conveniently divided into four classes, — albumens, fats, 
starches and sugars, and inorganic constituents, — the type, force-value, 
composition, and chief constituents of which are well exhibited in the fol- 
lowing table, quoted from Ralfe -} 



Class. 


Type. 


Force-Vai.ue 
OF Fifteen 

Grains in the 
Dky State. 


Composition. 


Chief Constituents of 
Articles of Diet. 


i. Albumens. 


White of egg. 


13,851 foot- 
pounds. 


C72"ll2-^18^23- 


Plesh (myosin), bread 
(gluten), cheese (ca- 
sein). 


ii. Fats. 


Butter. 


27,716 foot- 
pounds. 


^zT^vaS^s- 


Fat or meat, milk, but- 
ter. 


iii. Starches, 
sugars. 


Starch, grape- 
sugar. 


11,720 foot- 
pounds. 


CfiH^oO,. 


Potatoes (sago), honey, 
cane-sugar, grape- 
sugar in beer or wine. 


iv. Inorganic 

constituents. 


Water. 


Not known. 


H^O. 


Common salt (chloride 
of sodium), bone-earth 
(phosphate of lime) 
in millv, bread, and 
meat, alkaline salts in 
meat and vegetables. 



Liebig's classification into tissue-making and heat-producing foods is 
excellent: there is, however, no distinct line of demarcation between them, 
for, although some foods are especially heat-producers, all tissue in its com- 
bustion produces heat, and heat-making substances, like inorganic substances 
^nd carbo-hydrates, make tissue as well as albuminous ones. 

Of the most important chemical elements entering into the composition 
of the food, carbon and nitrogen, it is significant that nitrogen is contained 
only in albuminous foods, and further, as this element is present in every 
tissue which exhibits energy, the food which contains it must be considered 



1 Op. cit., p. 55, Exercise and Training. 



292 PHYSICAL DEVELOPMENT. 

as essential. Taken exclusively, however, albuminous foods are highly un- 
economical. It is estimated that, in a state of health, one grain of nitrogen 
is excreted for every fifteen grains of carbon. 

" If a man should confine himself to vegetable food, — say bread, for 
example, — for every grain of nitrogen that he ate he would take in not only 
fifteen grains of carbon that are necessary, but fifteen grains too much; in 
eating meat alone, while he obtains the one grain of nitrogen, he gets only 
about three grains of carbon, — twelve grains too little. He must eat, 
therefore, nearly five times as much meat as is necessary, so far as the 
amount of nitrogen is concerned, in order to get the fifteen grains of carbon, 
and in so doing he loads his system with five times too much nitrogen. In 
eating bread you get twice as much carbon as is needed, and in eating meat 
four times too little. In diminishing the amount of bread you get too little 
nitrogen, and in increasing the amount of meat too much. If, however, 
the bread and meat are taken together in proper proportions, we will get, 
according to the above calculation, the ratio of sixteen of carbon to one of 
nitrogen in the excretions, which differs but little from that actually found, 
one to fifteen, and which can be accounted for by remembering that the food 
of man consists not only of bread and meat, but of other substances con- 
taining carbon and nitrogen." ^ Or, as Prof. Huxley has aptly said,^ " a 
man conliued to a purely albuminous diet must eat a prodigious quantity 
of it ; this not only involves a great amount of physiological labor in com- 
minuting the food, and a great expenditure of power and time in dissolving 
and absorbing it, but throws a great quantity of wholly profitless labor on 
those organs which have to get rid of the nitrogenous matter, of which 
three-fourths is superfluous." 

Carbon is the essential element of force, and the fatty principles of 
food yield in their combustion double the force-value of an equal quantity 
of albumen or starch, for the carbon is stored up in fat to the amount of 
eighty per cent., while in albuminous matter and starch there are but fifty- 
three per cent, and forty per cent, respectively. The carbon thus stored up 
in the fat of the body also possesses this advantage, that it is always ready 
for immediate use. On the one hand, man cannot live in good health with- 
out fat, and, on the other hand, he can live but a short time upon fat alone. 
The physiological eifect of a carbo-hydrate diet — converted starch and sugar 
— does not differ essentially from that of a fatty diet, except that the com- 
ponents of the former are more readily oxidized, seventeen parts of sugar 
being equivalent to ten parts of fat, and that in some occult manner they 
play an important part in promoting nutrition. 

The importance of the inorganic constituents — water, sodium chloride, 
phosphate of lime, and the alkaloid salts of sodium and potassium — is so 
w^ell understood that it is only necessary here to refer to them. 

1 Chapman, Treatise on Human Physiology, p. 39. 

2 Lessons in Elementary Physiology. 



PHYSICAL DEVELOPMEXT. 293 

Variety axd Quantity of Food. — The anatomical construction of 
the alimentary tract (especially the diminished posterior molars and the 
modified canal mid\yay bet\yeen that of the herbivora and that of the car- 
uivora) and the analysis of the excreta indicate, what experience proyes, 
that a mixed diet best meets the requirements of man. 

The quantity of food that a man should eat to live is very different 
from what he can eat and live. In this connection it may be mentioned 
that, according to Sir Edward Parry, a youiig Esquimau is said to have 
eaten thirty-five pounds of food in twenty-four hours ; and " Captain Coch- 
rane, on the authority of the Russian admiral Saritcheff, tells how one of 
the Yakuts consumed the hind C[uarter of a large ox in twenty-four hours, 
together with twenty pounds of fat and a proportionate quantity of melted 
butter. As the man had already gorged himself in this disgusting fashion, 
it hardly seemed possible that he would be able to consume any more ; but 
the M'orthy Russian admiral, to test him, gave the savage a thick porridge 
of rice boiled \vith three pounds of butter, weighing together twenty-eight 
pounds. The glutton sat down to this abundant banquet, although he had 
just partaken of breakfast, and, without stirring from the spot, or showiug 
any sign of inconvenience, got through the whole." 

On the other hand, Cornaro is reported to have lived for forty-eight 
years on only twelve ounces of vegetable matter and fourteen ounces of 
light wine daily ; and Thomas Wood for eighteen years lived on a daily 
allowance of sixteen ounces of flour made into a pudding with water. 

These represent the extremes, and it remains to estimate the amount of 
food required by the average man in twenty-four hours. 

From the estimates of Prof. Dalton, "the entire c^uantity of food re- 
quired during twenty-four hours by a man in full health and taking free 
exercise in the open air is as follows : 

Meat 453 grammes (16 ounces) 

Bread 540 " (19 " ) 

Butter or fat 100 " (3^- " ) 

- Water 1530 " (52 " ) 

"That is to say, rather less than two and a half pounds of solid food 
and rather more than three pints of liquid." So there must be added from 
time to time fresh vegetables, fruit, milk, tea, coffee, and sugar, to contribute 
variety and maintain health. 

From the exact data furnished by modern physiological research elabo- 
rate dietaries have been constructed, exhibiting the amount and variety of 
food required for youths in training ; but such tables for physical use are 
unnecessary, and Dr. J. "William White has expressed the whole subject 
"in a nutshell" in his admirable article on "Exercise and Athletics."^ 

^ A Physician's View of Exercise and Athletics, Lippincotfs Magazine, June, 1887, 
p. 1024. 



294 PHYSICAL DEVELOPMENT. 

" The diet," he says, " should be plain and sensible, and should not contain 
an excess of either animal or vegetable food. An ordinary farm-house 
table, with its mid-day dinner and early tea, will rarely (with the exception 
of coffee, hot cakes, pastry, and fried meats) offer anything which should 
be excluded from rational training diet as it is at present understood." 

The amount of fluid required in twenty-four hours in training is about 
five pints in winter and six pints in summer, a considerable portion of 
which (about one and three- fourths pints) will be contained in the food 
taken. Water should not be drunk shortly before taking exercise, or large 
quantities during or immediately after meals ; nor should a dry, parched 
condition of the mouth and throat be mistaken for genuine thirst. This 
should be first relieved by rinsing the mouth and holding water in it for a 
short time, and then the actual need for fluid in the system may be supplied 
by frequent small draughts at short intervals. During training, tobacco, 
and especially cigarettes, being a depressant upon the heart, should be posi- 
tively forbidden. 

Alcohol, if allowed at all, should be used in the greatest moderation, 
and be limited to light table ales, light beer, or red wine. The reaction 
from the great restrictions of the past has led to too great laxity in the use 
of alcoholic beverages during training. 

As pointed out by Dr. Parkes, " a small quantity of alcohol does not 
seem to produce much effect, but more than two fluidounces manifestly 
lessens the power of sustained and strong muscular work. In the case of 
a man on whom I experimented, four fluidounces of brandy (j= 1.8 fluid- 
ounces of absolute alcohol) did not apparently affect labor, though I cannot 
aflirm it did not do so ; but four ounces more, given after four hours, when 
there must have been some elimination, lessened muscular force ; and a 
third four ounces, given four hours afterwards, entirely destroyed the power 
of work. The reason was twofold. There was, in the first place, narcosis, 
blunting of the nervous system, — the will did not properly send its com- 
mands to the muscles, or the muscles did not respond to the will ; and, sec- 
ondly, the action of the heart was too much increased, and induced palpita- 
tion and breathlessness, which put a stop to labor. The inferences were 
that any amount of alcohol, though it did not produce narcosis, would act 
injuriously by increasing unnecessarily the action of the heart, which labor 
alone had sufficiently augmented. I believe these experiments are in accord 
with common experience, which shows that men engaged in any hard labor, 
as iron-puddlers, glass-blowers, navvies on piece-work, and prize-fighters 
during training, do their work more easily without alcohol." 

Bathing. — For its physiologically stimulating effect upon the nervous 
and circulatory systems the cold bath is now so generally adopted that it 
requires simply to be mentioned in this connection. If it be employed 
immediately after the exercise of the day, it may be omitted on rising or be 
substituted with advantage by the sponge-bath. In either case it should be 
followed by vigorous friction with a coarse towel. Occasionally in addition 



PHYSICAL DEVELOPMENT. 295 

the warm bath with an abimdauce of pure soap should be employed, tq 
cleanse the skin thoroughly, and this will best be taken before retiring 
at night. This will regulate the action of the skin, and diminish, if not 
entirely remove, the necessity for sweating as formerly employed. 

The bowels should be regulated, and constipation, often a serious an- 
noyance, carefully guarded against. For this purpose some of the milder 
laxatives and salines should be prescribed, preferably the natural mineral 
watei"s. 

If during training nervousness, sleeplessness, inattention, loss of appe- 
tite, diminution in weight, exhibit a tendency to " training off," a little 
extm attention to the minutiae of training will correct them ; but, if the 
heart becomes intermittent or irritable, and breathlessness ensue, a physi- 
cian should at once be consulted, to ascertain if any pathological cause exist. 

The amount of work daily performed by a crew in training will depend 
much upon the ultimate exertion to be undertaken, for the crew that has 
but a half-mile or mile race will not need the severe training required for a 
three- or four-mile race. In the selection of the crew attention must be 
paid to the muscular development and the breathing-power, particularly to 
the latter, since the severest strain at the most important period of the 
contest will be thrown upon the heart and lungs. 

The period of actual training includes from three to six weeks, and 
during this time the following schedule may be taken as an example of a 
single day's work. 

Rising at six in summer and seven in winter, the cold bath is immedi- 
ately taken. After dressing slowly, a brisk walk or run is taken about the 
track, to develop the " wind." Breakfast is served at eight, and consists 
of an egg, one or two chops or a piece of steak and greens, with bread and 
butter and a pint of milk. From breakfast till noon is occupied with the 
usual college duties, an hour being taken, if possible, for some light gym- 
nasium work, the exercises at this time being particularly directed to those 
parts which are not employed in the more important exercise of the day, 
thus fulfilling the rule already quoted of exercising all the muscles. 

A light lunch of cold meat, bread and butter, with milk, water, or tea, 
is taken, and an hour and a half or two hours later the principal exercise 
of the day begins. For the boat crew this will consist of from one and a 
half to two and a half hours at the machines or on the river, at one-half, 
three-fourths, or full speed, or alternating, at the pleasure of the trainer. 

On returning to the house the men are immediately sponged down and 
rubbed down briskly, after which a short rest precedes the principal meal 
of the day. One cold bath a day is sufficient. This meal or dinner, as 
pointed out before, will exclude few articles found upon the ordinary farm- 
house dinner-table (except hot cakes, coffee, fried meats, pastry, etc.), and 
should be heartily partaken of. At ten o'clock a light tea of crackers 
and milk or thin oatmeal gruel may be taken, and at eleven o'clock they 
retire for the night. 



296 



PHYSICAL DEVELOPMENT. 



If the principal exercise of the day be taken in the morning, a mid-day 
dinner from twelve to half-past one should follow it, with the interval of 
rest between. 

The results of systematic exercise engaged in for only a limited time 
are remarkable, as evidenced by the following table, showing the effect of 
four months and twelve days' exercise, under Maclaren's system, on fifteen 
youths ranging from sixteen to nineteen years of age. 



No. 


Age. 


Measueemknts, etc. 1 


Increase. 








- 










S' 








to 


1 


1 




M 


U) 




S 


2 


a) S 






'S 


Q) 

^ 




g 


&< 


'S 


i 


6 


g 


In. 






FL. lu. 


St. Lb. 


In. 


In. 


In. 


In. 


Lbs. 


In. 


In. 


1 


18 


/5 U 
\5 21- 


7 8 
7 8 


29 V 
30' 


9.^ 

si- 


811 


1 




§ 




J 


2 


19 


fo 8.V 
15 8| 


9 5.V 
9 U 


28 
3U 


ll 

11 


ion 
lit/ 


i 


5} 


3]- 




n 


3 


17 


f5 5| 
15 6^ 


9 1 

9 1 


26* 

29^ 


10| 


10 1 


8 




3 




n 


4 


18 


15 8.V 


10 
10 3 


33" 
35 


lOJ 
lOJ 


ion 
lul 


} 


3 


2 




li- 


5 


18 


f6 0.V 
\6 H 


10 13 

11 2 


32 
34 


10.^ 
lOj 


9}i 
mi 


f 


3 


2 




lt 


6 


17 


f 5 3.V 

\6 41 


8 1 

8 7 


31 
33 


101 


911 

11 / 


1 


6 


2 




u 


7 


18 


f 5 5t 
15 5J 


7 13 

8 2 


26 

29 


9]- 
9| 


7n 

9*1 


1 
2 


3 


3 


i 

4 


If 


8 


16 


f5 6i 

15 n 


8 3 
8 4 


28.1- 
31" 


9 
9| 


8*1 
9|/ 


i 




2J 


4 




9 


17 


/ 5 81 
15 9.} 


11 3 
11 3 


31 
33 




ion 


1 


1 


2 


* 


7 


10 


18 


f5 111 
15 llf 


11 8 
11 8 


30 
33 


101- 
10| 


lO.Vl 

11' 1 


3 

4 




3 


1 

2 


1 


11 


19 


f5 7| 

15 8| 


10 2 
10 2 


33 


lO.V 
lOi 


ion 

lOlf 


1 




IJ 


i 


1 


12 


18 


(5 m 

15 111 


10 11 
10 11 


32" 
33 J 


lOl 

loi 


10 1 

11 1 


If 




n 


i 


1 


13 


19 


15 9| 


11 13 
11 13 


33" 
35.V 


lU 
lU 


12 I 


If 




2J 


i 


i 


14 


17 


f5 6| 

15 7i 


9 13 
10 3 


29 
32 


lOf 

io| 


8n 

9H 


1 


4 


3 


1 


n 


15 


19 


/5 lOi 
15 111 


10 1 
10 9 


27J 
32| 


lOf 
lOf 


10|| 


If 


8 


SI- 


§ 


n 



EXEKCISE FOR GIRLS. 

At the present time, when women are striving to engage in so many 
of man's burdens and responsibilities, and are even desirous of competing 
with him in the cares and duties of professional life, the subject of exercise 
for girls assumes a new and greater importance, and the physical training 
of girls, the co-education of the sexes, and employment for young women 
appeal to every one interested in children and their development. 

During early childhood boys and girls are very much the same. They 
walk, talk, romp and play, love and hate, with an innocent abandon ignorant 



PHYSICAL DEVELOPMENT. 297 

of sex. But to the observing the clifFerence even here is apparent. The 
infant Ulysses breaks the thin disguise of gown and sleeves, dropping the 
distaff to grasp the sword, while the baby Andromache, inspired with the 
divine instinct of motherhood, scarcely able to creep, caresses the diminu- 
tive image of herself. With the advent of puberty the sexes diverge. 
The unmistakable difference of face and feature, form and limb, denotes a 
change of mind and matter, and reveals the demand for a special training. 
From the time of Hippocrates woman has been described physiologically 
as enjoying a tripartite life, the divisions being marked by the advent 
and disappearance of the catamenial function. The lines of separation, 
diverging as childhood recedes, again unite as old age approaches ; and 
Shakespeare's description of senility, — 

" Last scene of all, 
That ends this strange eventful history, 
Is second childishness and mere oblivion, 
Sans teeth, sans eyes, sans taste, sans everything," — 

applies alike to both sexes, and humanity as a sexless being passes the portal 
of death. With the first and a portion of the second tripartite state of 
women we are concerned. 

Until the age of nine or ten is reached, girls, as a rule, are allowed to 
exercise and mix on equal terms with their brothers, whom they often excel 
both in spirit and in skill. From this time on, the decrees of fashion impose 
a bondage upon the movements of the female, and the decorous girl must 
abandon her romps and games and be content to confine herself in stays 
and tight boots and exercise the regulation walk. At this period systematic 
physical development should be commenced. There should be in o])eration in 
every girls' school, academy, and college a system of physical education similar 
to that employed in men's colleges, which should first eradicate any special 
defects and weaknesses, and then create, develop, and maintain the symmetry 
of parts, gradually increasing the strength and bodily vigor up to maturity. 
In this connection, as an example of what may be done, a rapid sketch of 
an hour's exercise, as given by Miss Mary E. Allen, director of the Allen 
Gymnasium, Boston, may be cited •} " Putting each pupil into an abso- 
lutely unfettered costume, we begin the hour with a series of free move- 
ments, without apparatus, which exercises certain sets of muscles from head 
to foot in regular succession, the object being gently to accelerate the cir- 
culation and to limber the joints. Following this will come, perhaps, an 
exercise on the breast-bars, upright bars about eighteen inches apart, which 
gives a little harder work, but which concerns only localized parts of the 
body. By this time the muscles are sufficiently warmed to bear more strain, 
and a hard pull at the chest-weights exercises from head to foot, though 
the trunk and arms get the main share. Following this, leg-development 
is in order, and a jump over a light rod which is displaced if a trip occurs, 



1 American Association for the Advancement of Physical Education, 1890. 



298 PHYSICAL, DEVELOPMENT. 

with a landing upon a very soft mat, fills the demand ; by this time the 
respiratory muscles are ready for enforced work, and a set of deep breathing- 
exercises, gently and gradually increased in force, oxygenizes most fully the 
blood as it flows to the lungs, strengthens them, and furnishes strong action 
to various respiratory muscles, as the diaphragm, intercostal, and abdominal 
muscles, with stimulation to the organs situated in juxtaposition, as the 
stomach, liver, etc. These breathing-movements, of Avhich I make large 
use, they being a prominent feature of our work, are taken by the class 
lying down, and thus relief is afforded to the spine and brain. In addition, 
various other exercises are given in the recumbent position, to strengthen 
the back and lateral muscles. Now a wooden-dumb-bell drill gives stronger 
all-over work than the free movements, and a run up the ladders and round 
the running track again carries the work into the leg muscles, while the 
thorax receives its share of gain in increased respiration. Indeed, some 
authors ascribe stronger development to the thorax by leg exercises than by 
those of the arms. A complete rest is now in order, and the whole class, 
donning their wraps to prevent any liability to chill, stretch for a few min- 
utes upon the mats. The attraction of the vaulting bar is next presented, 
where the exercise gives courage, elasticity, and agility. Then, perhaps, an 
iron-dumb-bell drill, adding still stronger all-over training than the wooden- 
bell drill, is succeeded by a brisk, lively, competitive game of bean-bags, 
which induces profuse perspiration, after which the class is drawn into 
marching order and instruction in carriage and gait is given by a series 
of marching, hopping, and skipping movements, and the class is dismissed, 
exhilarated, buoyant, and hot, to its refreshing bath and fresh clothes. 

" Thus you notice that no one set of movements is continued for longer 
than six or eight minutes. So the mind is kept healthily occupied by 
diversity of work, and a large number of muscles are gently exercised, 
insuring symmetry of development, and much more exercise is accom- 
plished than by the use of harder movements on a few machines. In class 
work, every exercise possible is performed to the accompaniment of music, 
in which I most heartily believe. 

" As the years increase, the body demands harder work, and exercises 
above the floor on high parallel bars, where the weight is held by hands 
over the head ; low parallels, where the weight is suspended or held by the 
shoulders ; travelling rings, where the weight is held by one hand ; climb- 
ing and shinning exercises, — are added, according to development." 

In addition to this, out-door games should be a regular part of the 
curriculum, and swimming should be regularly taught, not alone for the 
protection it aifords, but also for its excellence as an exercise bringing 
into play all the muscles of the body. Another useful exercise is rowing, 
which should be engaged in whenever the opportunity offers, strengthening 
and developing nearly all the muscles of the body. Equestrian exercise 
is also excellent if used in moderation, especially until the full growth is 
attained. The recognition of the importance of exercise for girls has of 



PHYSICAL DEVELOPMENT. 



299 



late years become so general that little need be added. The great diffi- 
culty in providing suitable places for ladies to exercise is the expense; 
but this is being solved, in the larger cities at least, by the establishment 
of ladies' clubs, and the unions formed in connection with men's athletic 
associations. 

TABLE 

Showing Average Heights and Weights of Boston School-Girls, irrespective of Nationality.^ 



Age. 


Occupation 


OF Parents 






Non-Laboeing. 


Laboring. 


No. of Ob- 


Height, 


Weight, 


No. of Ob- 


Height, 


Weight, 




servations. 


Inches. 


Pounds. 


servations. 


Inches. 


Pounds. 


5 j'ears ....... 


120 


41.66 


40,55 


491 


41.26 


39.48 


6 " 


172 


44.12 


44.14 


809 


43.24 


43.13 


7 " 


247 


45.71 


48.02 


921 


45.41 


47.16 


8 " •. . 


297 


47.92 


52.79 


982 


47.47 


51.81 


9 " 


224 


50.16 


58.78 


918 


49.27 


56.74 


10 " 


232 


51.66 


68.76 


854 


51.25 


61.98 


11 " 


210 


53.66 


70.49 


719 


53.41 


68.01 


12 " 


237 


56 16 


80.18 


671 


55.70 


77.52 


13 " 


191 


58.67 


90 68 


593 


58.01 


87.88 


14 " 


226 


60.28 


99.40 


419 


59.84 


97.92 


15 " 


168 


61.19 107.70 


258 


61.00 


105.11 


16 " 


147 


61.46 


111.22 


169 


61.55 


112.59 


17 " 


98 


61.88 


115.15 


89 


61.92 


115.72 


18 " 


77 


62.26 


115.83 


46 


61.70 


112.94 



According to the tables of Dr. Bow^ditch made from measurements of 
Boston school-girls from five to eighteen, irrespective of nationality, there 
is in children of the non-laboring class an increase in height from five to 
thirteen years from 41.66 inches to 58.67 inches, while the weight is nearly 
doubled. From thirteen to fourteen the increase is 1.61 inches, from four- 
teen to fifteen it is less than one inch (.91), from fifteen to sixteen a little 
over one-fourth of an inch (.27), from sixteen to seventeen less than half 
an inch (.42), and from seventeen to eighteen less still (.38). These figures 
are for the most part greater than in the children of the laboring class, and 
both tables show a steadier and more regular increase and one extending 
over a longer period than in boys of the same age. The importance of these 
deductions is twofold, — showing that girls require throughout a longer period 
the utmost care that they are not overtaxed, and also that during the later 
part of this period they should not be subjected to excessive study, but 
should be permitted to perfect their development. 

If we compare the average girl of to-day with the ideals beheld in the 
pictures and statues of the past, — the well-developed and shapely arm and 
shoulder, the high chest, the vigorous body, and the firm and erect carriage 
of the Minervas and Niobes, Venuses and Junos, of mythology, the Helens, 



^ Bowditch. 



300 PHYSICAL DEVELOPMENT. 

the Madonnas, and the mediseval beauties, — there is at once a consciousness 
that something radically wrong exists. Instead of tliis galaxy of beautiful 
parts, a vision of pipe-stem arms, scrawny necks, angular shoulders, flat 
chests, narro^v backs, stooping carriage, and weak walk, recalls us to the 
realities of the present. If we further compare the brilliant eye, the 
damask cheek, and the luxuriant form of the robust English damsel, the 
sturdy German fraulein, or the hardy Provenyal maiden, with the vacant 
gaze, pallid features, and attenuated figures of the fragile, easily-fatigued, 
languid girls, the products of modern American habits and customs, the 
contrast is equally striking, showing that there is a conservation of foi'ce 
on the part of the trans- Atlantic female, and a deterioration of force on the 
part of her cis- Atlantic civilized sister. 

As pointed out in the first section of this article, the statues of the god- 
desses of the Greeks were taken from models who from attention to physical 
culture were ideals of health and symmetry ; and the moral is evident that 
the errors which exist in our present system of female education are the 
lack of proper physical exercise, and a disregard for the obligations which 
sex imposes upon the developing females. 

But there is one fact that is constantly brought to the notice of the 
physician, and it is his duty to caution against it, and that is that girls who 
become enthusiastic in any form of exercise are apt to disregard totally the 
catamenial function. Cases have been known where champion matches 
have taken place during the menstruation of one of the players. The 
strain and over-exertion incident to the contest would certainly have a 
baneful influence on the sexual organs at this time. The same must be 
said of fatiguing horseback-rides, long drives with exposure, mountain- 
climbing, swimming, and the like. The injury done under such circum- 
stances is illustrated in the note-books of gynaecologists. 

Remarkable degenerative changes have occurred during the develop- 
mental period, the most important era in a Avoman's existence. There has 
been a disregard of the four conditions considered requisite by Clarke^ 
for the projDer education of the female : " first, a sufficient supply of ap- 
propriate nutriment ; secondly, a normal management of the catamenial 
functions, including the building of the reproductive apparatus ; thirdly, 
mental and physical work so apportioned that repair shall exceed waste, 
and a margin be left for general and sexual development ; and, fourthly, 
sufficient sleep." 

Then, again, dress has had a share in producing these changes. The 
gifted authoress of " The Gates Ajar" and her followers, in their explana- 
tion and advocacy of a new clothes-philosophy, have done much to eman- 
cipate women from "corsets that embrace the Avaist with a tighter and 
steadier grip than any lover's arm, and skirts that weight the hips with 
heavier than maternal burdens." 

1 Clarke, Co-Education, p. 60. 



PHYSICAL DEVELOPMENT. 301 

GYMNASTICS. 

The traditional history of the Chinese, the superstitious religious prac- 
tices of the ancient Indians, the earliest mythological fables of the Egyptians 
and Greeks, all contain references to the employment of exercises for the 
restoration and preservation of the health and the improvement of all the 
faculties. 

Pliny tells us that Asclepiades, who lived in the second century B.C., 
cured all diseases by physical exercises alone, and justified his declared 
willingness to forfeit all claims to the title of physician should he ever 
fall ill except from accident or senility, by living for more than a cen- 
tury and dying eventually from the effect of an accident. The relation 
which was thus early established, both in history and in tradition, between 
physical exercise and health and longevity became later, as among the 
early Chinese, the vital principle of civilization of all the more powerful 
nations of the world. In Greece, and especially in Sparta, the idea of 
personal hygiene, or physical culture as we now call it, overtopped every 
other, and resulted in a type of physical perfection which has never since 
been equalled. The Romans, eminently a warlike people, appreciated the 
value of exercises only so far as they promoted the physical force for mili- 
tary purposes. 

With the increase of luxury and vice, the gymnasia declined in repu- 
tation and favor, and, when Greece and Rome began their uninterrupted 
descent in the scale of nations, gymnastic and athletic proficiency likewise 
declined, to become in the Middle Ages almost the exclusive property of 
the nobility and professional soldiery. During all this period there existed 
but a vague and empirical estimate of the true value of movements, exer- 
cise, gymnastics, etc., and it was not until the beginning of the present cen- 
tury that gymnastics became systematized and popularized. In 1811 Jahn 
established in Berlin his gymnasium or Turnplatz, introduced new appara- 
tus, improved the defective system, published his celebrated essay on the prin- 
ciples of gymnastics, and established the Turnvereine. The success of these 
and the energetic aids of Guts-Muths and Spiess led to the establishment 
of similar societies in Switzerland, Sweden, and France, and later in England 
and in our own country. It remained, however, for Peter Henry Ling, a 
native of Sweden, in 1816, with a remarkable intuitive grasp to collect and 
arrange the scattered fragments and shifting facts, to separate the real and 
rational from the superstitious and empirical, and to create with the aid of 
anatomy and physiology, upon a philosophical and scientific basis, a system 
of movements and exercises for the development and perfection of the 
whole body. It is a little over fifty years since Ling departed, and still, 
as Dr. Richter, the great physician of Hanover, said, " his principles are 
incontestable." He had learned, in a life of vicissitudes and excitement as 
a fatherless boy, a theological student, a tutor, a naval volunteer, and a 
fencing-master, the value of a sound body; and, as a leading French 



302 PHYSICAL DEVELOPMENT. 

authority has said, " if he was not the creator of the modern, scientific 
gymnasium, he was its regenerator." 

AVhat is implied by exercise has already been described. Movements 
include more : they are motions of specific kinds, having specific effects, 
employed for specific purposes, and practised to secure definite results. 

As pointed out by Taylor, " movements are mechanical agencies, di- 
rected either upon the whole system or a part of it, for the purpose of 
inducing determinate effects upon its vital actions, and generally having 
reference to its pathological state." 

MovEMEXTS. — Movements are conveniently divided, according to the 
source from which the moving power is derived, into active and passive. 
They are also said to be single when but a single person is engaged in their 
execution, and duplicated when more than one is engaged. All the move- 
ments to be described in the first part of this section are single, but in the 
second part they are of the second variety. These second or duplicated 
medical movements are also of two varieties, of each of which examples 
are given. In one the patient, quite passive, receives the motion of some 
particular variety given by the physician or operator ; in the other the 
patient is required to bring into action some particular part, the quality, 
amount, and duration being entirely controlled by the physician or gym- 
nast.^ The degree and kind of resistance employed by the operator in his 
or her manipulations require a variety and nicety in the different stages simi- 
lar to the delicacy of touch employed by musicians for giving expression 
and effect in instrumental performances, constituting a tadus eruditus that 
cannot be acquired from books. 

Movements are also described as concentric when the muscular contrac- 
tion steadily increases, and eccentric when the muscle is stretched and its 
muscular contraction steadily decreases. From the explanation already 
given of the physiological action of muscular tissue, from the common ex- 
periences of every-day life, and from the fact that " fatigue is in proportion 
to the amount of mental and nervous rather than to the amount of mus- 
cular action employed," it is evident that all movements should be slowly 
performed, from a particular position or base, and the more prolonged the 
movement the greater the amount of muscular exercise in proportion to the 
time occupied, especially in the respiratory exercises and the trunk move- 
ments generally on account of the vital organs contained. 

Swedish Movements. — According to Prof Ling, gymnastics are 
divided into four great classes : 

1. Pedagogic or school gymnastics (subjective active), in which the 
person through his own strength exercises and develops the power to 
control his own body by his own will. 

^ The term gymnast designates a graduate from the Eoyal Gymnastic Central Institute, 
Stockholm, Sweden. We desire here to express our indebtedness to Miss Anna Jonsson, 
of Philadelphia, who is a graduate of this institution, for much assistance in the preparation 
of that portion of this article which relates to the Swedish system of gymnastics. 



PHYSICAL DEVELOPMENT. 303 

2. Military gymnastics (objective active), in which one person exercises 
or contends with anotlier outside will, and by his own muscular power or a 
weapon of some character masters another's will. 

3. Medical gymnastics (subjective passive), in which a person endeavors, 
through certain positions or with the resistance of other persons, to cure or 
relieve disease produced by a disturbance of the organism. 

4. -ZEsthetic gymnastics (objective passive), in which the person by a 
motion or gesture endeavors to reflect his thoughts, emotions, feelings, etc. 

The movements employed in the Swedish system may be described 
under the different regions included, as the head and neck, arms, trunk, 
etc., but are most conveniently classed under the following divisions : 

Educational Gymnastics. — 1. Fundamental positions. 2. Arch flexions. 
3. Heaving movements. 4. Balance movements. 5. Shoulder-blade move- 
ments. 6. Abdominal exercises. 7. Lateral trunk movements. 8. Slow 
leg movements. 9. Jumping and vaulting. 10. Respiratory exercises. 

Medico- Gymnastic Exercises, — Respiratory exercises. General health 
exercises. Exercises for lateral curvature. 

The introductory exercises are intended to secure general attention and 
muscular control, and to correct the general equilibrium and base of support 
before the more difficult exercises are undertaken. These include the for- 
mation of the lines, numbers, changing position, easy feet and leg move- 
ments, head movements, certain arm and trunk movements, and marching, 
all of which require about five or ten minutes. The calisthenics which im- 
mediately follow should occupy only from twenty minutes to half an hour. 

The arch flexions comprise various forms of backward flexions of the 
trunk, and are given for the purpose of strengthening the dorsal spine, 
expanding the lower portion of the chest, and stretching the upper portion 
of -the abdomen. 

The heaving movements comprise forms of self-suspension by means 
of the arms on a horizontal bar or other apparatus, and are given for the 
purpose of expanding the upper chest and strengthening the arms. 

The balance movements are positions taken from a smaller area than 
that included within the feet in standing, the difficulty being increased by 
the altitude of the supporting surface and the diminution of the area of 
support. They are introduced to develop the equipoise of the body and 
to secure grace and beauty of action. 

The shoulder-blade movements are various forms of arm movements 
intended to correct the position of the shoulder-blades. 

The abdominal exercises bring into play chiefly the muscles of the abdo- 
men, and are employed not alone to strengthen the abdominal walls, but 
also secondarily to affect the digestive organs. 

The lateral trunk movements include various forms of sideways bend- 
ing and twisting of the thorax, and are employed to strengthen the muscles 
about the waist, but also influence secondarily the organs in this region, 
especially the digestive. 



304 



PHYSICAL DEVELOPMENT. 



The jumping and vaulting are employed to promote the general elasticity 
and grace of the body. 

The respiratory exercises counteract the ill effect of the preceding exer- 
cises, and are employed to diminish the frequency of the heart-beat and 
render the breathing less labored. 

The proper arrangement of the order of the movements is very impor- 
tant, to enable the pupil or patient to secure uniform and beneficial results. 
For this purpose Prof. Ling proposes the following order, subject to modi- 
fication in particular cases : 

1. A respiratory movement. 

2. A movement of the lower extremities. 
A movement of the upper extremities. 
A movement of the abdomen. 
A movement of the trunk. 
A movement of the lower extremities. 
A respiratory movement. 

The principal base position— standing — is as follows: Heels together, 
feet at a right angle (ninety degrees) with each other, knees extended, hips 
extended, rotated outward, and fixed, back muscles extended, scapulae fixed 
backward, fingers, forearm, and arm extended, hanging in a position between 
pronation and supination, neck extended, chin retracted, and the eyes fixed 
forward and upward. 

This position is so particular that its correctness would be destroyed by 
the lowering of an eyelid. 

The Swedish system has divided the principal base positions into five, 
of which the one above described is the principal one, to which are added 

the knee standing, lying, half- 



3. 
4. 

0. 

6. 

7. 



Fig. 7. 



The correct 



lying, and hanging 
base position must always be as- 
sumed before any other position 
is taken and before any move- 
ment may be undertaken from 
these secondary positions. 

Standing position. — Fig. 7. 
Foot grasp, wing forward, falling 
position. — In this position the 
left foot is fixed about one and 
one-half feet from the ground, 
the left leg being extended. The 
left leg extended, the back ex- 
tended, and the head kept for- 
ward and upward, the weight of 
the body is thrown upon the right leg, the knee of which is bent at about 
a right angle. The person must alternately change the feet, so that the 
whole body shall be exercised to the same extent. 




PHYSICAL DEVELOPMEXT. 



305 



Fig, 8. Wing balance standing, knee bending and extending. — The 
difficulty in this movement is to maintain the balance of the trunk when 
the person rests only upon one foot, while the opposite thigh remains 
horizontal and the leg is alternately extended and flexed. 



Fig. 9. 



Fig. 8. 





Fig. 9. Balance walking on horizontal bar. — In balance walking the 
eyes must be fixed forward and upward, the shoulders fixed backward, 
the chest expanded, the elbows slightly bent. The foot is advanced by 
slightly flexing the supporting knee, the leg describes a half-circle, and the 
toes are first applied to the bar, followed by the side of the foot and heel. 
The balance of the body is further assisted by the elevation and depression 
of the arms. 

Fig. 10. Wing standing, legs lifting sideways. — In this position the 
weight of the body is thrown upon the resting lower extremity and the 
same side of the body. The alternate lifting and sinking of the working- 
leg is accomplished by the concentric and eccentric action of the adductors 
and abductors. This movement may also be considered as a balance move- 
ment. The lower extremities are alternately exercised. 

Fig. 11. Stretch stride standing, trunk backward bending with sup- 
port. — By having the arms in stretch position and the support in this 
movement, the bending backward can be so far performed as highlv to 
Vol. IV.— 20 



306 



PHYSICAL DEVELOPMENT. 



influence the upper portion of the thorax, separate the lower ribs, aild 
extend passively the abdominal muscles. 

Fig. 11. 



Fig. 10. 





Fig. 12. Arch support standing, knee flexing and extending. — The 
hands are stretched and fixed to the bars, the body about two feet distant 
from the wall, so that the trunk and neck describe a curve in which the 
chest is well expanded. After assuming this position the knees are alter- 
nately flexed and extended. This position, as well as all arch standing 
positions, makes especial pressure upon the circulation in the vessels 
supplying the spinal column. 

Fig. 13. Hanging position. A. — The hands are parted about one and 
one-half feet and fixed upon the bar, the head upward and backward, 
chest expanded, shoulder-blades held backward, heels together, feet rotated 
at ninety degrees, the body hanging on the flexors of the arms, the principal 
trunk muscles, and the ligaments. 

Fig. 14. Underhanging, double arm flexion. B. — In this position the 
hands are parted as in the preceding position, but are passed beneath the 
bar and grasp the. upper side. Only by gradual exercise is the person able 
to elevate the entire body by the double arm flexion. 

Fig. 15. Bent hanging, double knee extending. — Bent hanging desig- 



PHYSICAL DEVELOPIMEXT. 



307 



nates a position in which the body is hanging by the hands on the bar. 
Avith both knees flexed forward and upward at a right angle. The move- 



FiG. 12. 




ment refers to the extension of the legs. The principal effect of this posi- 
tion is upon the abdominal, psoas major, and iliacus muscles, but the 
movement itself exercises strongly the extensor quadriceps femoris. 

Fig. 16. Bent uuderhanging, hand walking. — For bent underhanging 
see Fig. 15. The legs remain in the extended position. The hands are on 
either side of the bar; the body is slightly elevated and sloAvly moved 
backward by the alternate grasping and relaxation of the hands. This 
movement would be rendered much more difficult by moving tlie body 
forward. 

Fig. 17. Inclined rope climbing upward. — The hands grasp the rope, 
one over the other, the highest one being the opposite of the knee that 
crosses the rope. The walking upward is performed by alternately cliauging 
the grip of the hands and alternately swinging one leg and then the other 
across the rope, the hanging leg being ahvays fully extended. This move- 
ment combines the lifting with the trunk change turning movements. 

Fig. 18. Yard stride standing, trunk forward bending. — In the yard 
stride standing position the arms are extended and lifted horizontally side- 



308 



PHYSICAL DEVELOPMENT, 



ways, the feet are apart. Tlie motion is made by the flexors of the trunk 
forward. This movement by taking the yard standing position exercises 



Fig. 13. 



Fig. 14. 



-<IP 



^3>- 





the shoulder and back muscles (rhomboidei, trapezius, and latissimus dorsi), 
and it is therefore a valuable exercise in the treatment of lateral curvature. 

Fig. 19. Yard forward lying, arm bending and stretching sideways. — 
The heels are held down, and the hips only are supported across a bench, 
the upper part of the body and the neck being kept in an extended posi- 
tion forward and upward. The movement consists in horizontally flexing 
and extending the arms while in this position, the action upon the muscles 
being limited to the shoulder, back, and arms. 

Fig, 20. Stretch forward lying, arm bending and stretching upward. — 
This position differs from the preceding only in the movement of the arms, 
which are alternately flexed and extended downward and upward, exercisiug 
principally the muscles of the upper dorsal region. 

Fig. 21. Stretch lying, legs elevating. — The trunk is resting on a 
low couch, the arms stretched upward parallel and lying free upon the 



PHYSICAL DEVELOPMENT. 



309 



Fig. 15. 




^ 




310 



PHYSICAL DEVELOPMEN': 



Tig. 17. 




Fig. 18. 




PHYSICAL DEVELOPMENT. 



311 



EiG. 19. 







Fig. 20. 




Fig. 2L 






■ry 



312 PHYSICAL DEVELOPMENT. 

couch. The legs are kept in a horizontal position without any support, and 
from this they are elevated to a vertical position, strongly exercising the 
abdominal muscles. 

Fig. 22. Stretch knee stride standing, trunk backward bending. — In 
the stretch knee stride standing position the heels are together, the knees 
separated from fourteen to eighteen inches, the thighs extended, and the 
arms extended upward and parallel, the hands never being approximated 
nearer than tlie distance between the shoulder-joints. In the bending back- 
ward the trunk is slowly flexed backward, while the thighs still remain in 
the extended position, so that, although the muscular action is greatest upon 
the psoas, iliacus, and abdominal muscles, the flexion is confined entirely to 
the lumbar region. 

Fig. 23. Feet fixed, wing sitting, trunk backward bending. — The 
feet are fixed under the lowest bar, both entire lower extremities are ex- 
tended and resting upon the floor. The arms are in the wing position, the 
back extended, the scapulge fixed backward, the neck extended, the chin re- 
tracted, and the eyes fixed forward and upward. The body is slowly and 
alternately bent backward, and again elevated to the horizontal. This po- 
sition is one of the most important abdominal movements, exercising, as it 
does, the abdominal muscles, and producing a reflex stimulating action upon 
the abdominal viscera. 

Fig. 24. Feet fixed, arms stretch sitting, trunk backward falling. — 
The feet are fixed under the third bar of the " ribbed chair," ^ heels 
together, the toes rotated outward, the lower extremities, trunk, and arms 
extended, and the arms and trunk maintained in a horizontal position. The 
effect of this exercise is the same as that of the preceding, except that it is 
more intense. 

Fig. 25. Stoop falling position. — The body is supported by the hands 
and feet resting upon the floor. The whole body is held rigid, the heels 
together, and the hands separated the width of the shoulders and pro- 
nated and adducted. The body is alternately depressed and elevated by 
the flexion and extension of the arms. This movement expands and 
enlarges the thorax, develops the arm muscles, contracts the abdominal 
muscles, and strengthens the extensors of the legs and feet. It is a com- 
bined respiratory and abdominal exercise, and correctly taken it may be 
considered one of the most stimulating and strengthening movements for 
the development of the entire body. 

Fig. 26. .Horizontal stoop falling position. — This is identical with the 
preceding, except that the feet are elevated and supported in a position 
horizontal to the body. 

Fig. 27. Reverse stoop falling position. — This is the same as the pre- 



1 The name given to a Swedish apparatus consisting of a number of horizontal bars 
arranged about eight inches apart, one above the other, from the floor nearly to the 
ceiling. 



PHYSICAL DEVELOPMENT. 



313 



Fig. 22. 




Tig. 23. 




Fig. 24. 




114 



PHYSICAL DEVELOPMENT. 



Fig. 25. 




Fig. 26. 




Fig. 27. 




PHYSICAL DEVELOPMENT. 315 

ceding exercise, but with the feet elevated above the horixontal. The effect, 
however, is intensified, because ahnost the entire weiglit of the body is sup- 
ported upon tlie upper extremities. 

Fig. 28. Arms bent, support falling, leg elevating. — The body is sup- 
ported upon the flexed arms, the hands being fixed against a horizontal 
bar waist-high. The body is inclined downward and forward, with the 
heels resting upon the floor. The legs are alternately elevated and depressed. 

Fig. 29. Foot fixed, stretch balance standing, trunk sideways bend- 
ing. — The person standing upon one leg, the other foot is separated about 
half a yard and fixed at about twelve inches from the floor. The arms are 
extended parallel, and the trunk is flexed laterally to the side opposite the 
fixed foot. These flexions are then alternated by changing the feet. 

Fig. 30. Arms bent, trunk turn, stride standing, arm extending. — 
In this position the fingers are close together, the hands slightly flexed, 
the arms flexed, and the hands fixed to the tip of the shoulder, the chest 
expanded and the scapulse retracted, the feet separated about fourteen to 
eighteen inches to fix the hips, while the upper part of the trunk is rotated 
a quarter of a circle first to one side and then to the other. The motion is 
to extend the arms upward while in this rotated position. It may be 
repeated four to eight times each side. 

Fig. 31. Half stretch, half support, side falling, legs elevating. — This 
position is taken by supporting the entire rigid body with one hand upon 
the floor, prouated and adducted, and the side of one foot. The other arm 
is extended upward. The movement consists in elevating the upper leg 
and then approximating it to the other. This movement is performed from 
both sides, as it strongly exercises the lateral muscles of the trunk. 

Fig. 32. Sideways hanging position. — The hands are separated about 
three feet and fixed upon the bars so that the lowest one is one yard from 
the floor. By maintaining this grasp, and by exerting a strong contraction 
of the upper lateral trunk muscles, the legs are lifted sideways upward to 
a horizontal position. As soon as the exact position is secured, the feet are 
slowly lowered to the floor and the movement repeated upon the opposite side. 

Ling designates this as the most difficult — the final position — of his sys- 
tem of school gymnastics. It is generally undertaken only by boys, because 
the relatively heavier lower extremities and weaker lateral trunk muscles 
of girls render it much more difficult for the latter to perform. 

Fig. 33. Jumping in height on the place. — This exercise can be intro- 
duced by heels rising and knees bending, in which we have four counts, 
— heels rise, 1 ! knee bend, 2 ! knee extend, 3 ! heels sink, 4 ! In the 
jumping we add one more count, — 5 ! in which the jumping is performed 
on the third count by a sudden effort of all the extensor muscles of the 
lower extremities. The body descends upon the tiptoes, heels together, and 
bent knees, the trunk in upright position. To render the position easier, 
the arms may be lifted momentarily from the side and depressed in the third 
count. 



516 



PHYSICAL, DEVELOPMENT. 



Fig. 28. 




Fig. 30. 



Fig. 29. 




PHYSICAL DEVELOPMENT. 



317 



Fig. 34, Running jump. — The running is commenced by one step for- 
wardj 1 ! the other foot extended^ and the jump accomplished and termi- 






Fic. 31. 




Dated by bringing the feet together, 2 ! The body will descend in heels 
rising, knees bending position, in which the trunk will remain upright. 
Knee extension, 3 ! lowering of the heels, 4 ! 



Fig. 32. 




These movements may be rendered more complicated by adding more 
steps, and either allowing the children to count for themselves or omitting 
the counting altogether. 



318 



PHYSICAL DEVELOPMENT. 



Fig 



Fig. 35. High jumping. — The jump is preceded by a short run, to give 
momeutum, and if the bar is high the children may be allowed to have the 

"spring-board." In jumping over the bar the 
eyes must be fixed upward, the neck extended, 
the shoulder-blades back, the arms and trunk 
extended, and the thighs slightly flexed ; the 
knees must be very strongly flexed, and the heels 
kept together. The shock of the descent is re- 
ceived upon the extended toes, elevated heels, and 
flexed knees. This position is maintained for a 
moment, and the body is elevated by extending 
the knee, 3 ! and sinking the heels, 4 ! 

This can be made more complicated not only 
by elevating the bar, but also by increasing the 
length of the jump. Another modification of high 
jumping is turning during the jump, so that the 
body rotates a quarter of a circle or more in its 
flight. If the high jump is made from a higher 
to a lower level, this also increases the difficulty. 
Fig. 36. Vaulting;. — The bar must be fixed 
about waist-high. The hands are placed upon 
the upper surface of the bar, 1 ! A short double 
spring is taken, and the body is elevated, and 
rested npon the rigid arms and bar, 2 ! The 
hands are changed forward under the bar, 3 ! The 
vaulting over the bar is performed by changing 
the balance of the body by flexing the knees and bending the body forward, 
so that it is brought to the other side of the bar in the fall hanging posi- 
tion, followed by elevating the body to stretch arch standing position, 4 ! 
This position is raised to stretch standing position, 5 ! and ground standing, 
arms down position, 6 ! 

The exercise may be rendered more difficult by lowering the bar. 
The following eight exercises are selected from among all those included 
in the systems of Ling, as being ideal positions exercising together all the 
muscles of the body. Each one taken to its full extent stimulates especially 
the circulation, respiration, and digestive organs, as well as strengthens the 
nervous system both directly and reflexly. Taken together they may be 
considered a system in themselves, since they include exercises for every 
muscle in the body. 

Photo. VI. Neck rest standing, heels rising. — The wing standing, heels 
rising position is assumed from the first base (standing) position, but the 
hands are fixed at the hips, the thumbs backward, and the fingers firmly 
flexed about the waist. The elbows are pointed out sideways backward. 
In the heels rising position the heels are elevated as high as possible, so 
that the person stands on the tips of the toes. 




PHYSICAL DEVELOPMENT. 



319 



Fig. 34. 




Fig. 35. 




y 



320 



PHYSICAL DEYELOPMEXT. 



The muscles exercised are the following. Position : wing standing. 
Muscles : the deltoideus and supra-spiuatus lift the arm (upper part) hori- 



FiG. 36. 




zontally. Flexion of arm : biceps brachii ; brachialis anticus ; spinatus 
longus ; pronator radii teres ; flexor carpi radialis ; flexor uluaris ; palmaris 
longus ; flexor digitorum sublimis. Pronation of hand : pronator radii 
teres ; pronator quadratus ; flexor carpi radialis ; palmaris longus ; flexor 
digitorum sublimis. Fixation of arms and hands to the hips : pectoralis 
major; latissimus dorsi ; teres major et minor; subscapularis. Heels rais- 
ing, extension of feet : gastrocnemius ; soleus ; plantaris ; flexor digitorum 
communis longus ; flexor longus pollicis ; tibialis posticus ; peroneus longus 
et brevis. Extension of leg : rectus femoris ; vastus exteruus et internus ; 
cruralis. Extension and rotation outward of thigh, — Extensors : gluteus 
maximus, medius, et minimus (posterior part) ; obturator internus ; gemelli ; 
quadratus femoris ; biceps femoris (the long head) ; semitendiuosus ; semi- 
membranosus. Rotators outward : adductor longus, brevis, et magnus ; 
gluteus maximus et medius ; psoas major ; iliacus ; pectineus ; pyriformis ; 
obturator internus et externus ; gemelli ; quadratus femoris ; biceps. 

By taking the wing standing position the upper part of the thorax 



PHOTO. VT. 



PHOTO. YII. 




Neck Rest Standing, Heels Rising Position. Neck Rest Standing, Trunk Change Turning 

Position. 



PHOTO. VTTT. 



PHOTO. IX. 





Stretch Standlv^, Timnic shikways jii;Nij- 
ING Position. 



Stretch Stkide Staniuni;, 'ri:rNK Fcikwakd Bend- 
ing Position. 



PHYSICAL DEVELOPMENT. 321 

is elevated and fixed, the chest is expanded, the lungs are inflated, and 
the pressure on the heart and greater blood-vessels diminished, thereby pro- 
ducing increased oxygenation and increased circulation of the blood. The 
wing standing position also fixes the hips. The heels raising, alternately 
performed, stimulates the circulation in these parts, — flushes the parts, 
so to speak, — drawing the blood from the head, depleting the brain, 
and preventing "cold feet." This alternate movement also increases the 
secretion of the synovial fluid, preventing stiff ankle-joints. This move- 
ment may be repeated ten to twenty times. 

Photo. VII. Neck rest standing, trunk change turning. — In the 
neck rest position the arms are lifted upward and the hands rest behind 
the neck, with the tips of the fingers touching. The wrist-joints are ex- 
tended, the elbow is flexed, and the arms are abducted so that the elbows 
are directed outward. The scapulae are drawn backward; the neck is 
extended and the chin retracted. In the trunk change turning the hips are 
fixed, so that the turning is confined to the upper part of the trunk only. 
In the lower extremities the knees are extended, and the heels are kept 
together, with the feet at a right angle. 

Muscles exercised : in the position neck rest standing the scapulae are 
rotated, the arms are lifted, the weight of the forearms bends them, and the 
hands are pronated and fixed to the head by the muscles of the scapulae. 
Muscles : levator scapulae ; rhomboideus ; trapezius (upper and middle 
part). In turning the trunk the whole " muscle spiral is in contraction. 
Muscles : the pectoralis major and intercostales internus on the right side 
are contracted in the same spiral line as the pectoralis minor, serratus anticus 
major, and intercostales externus on the left side ; the obliquus abdominis 
externus on the right side is contracted in the same line as the obliquus 
abdominis internus on the left. All these muscles work together or turn 
the side forward ; on the back from the other shoulder. Muscles : the 
inferior part of the trapezius, latissimus dorsi, serratus posticus inferior in 
the same line as on the opposite side, multifidus spinae and intercostales 
externus. The direct muscles of the trunk and abdomen are also more 
or less in action, some concentrically and others eccentrically. 

The position neck rest standing has the same influence as the stretch 
standing, except that it affects all portions of the chest. 

The trunk change turning exercises the spiral muscles of the trunk, 
affecting particularly the vena cava inferior, and thereby stimulating the 
passage of the venous blood to the lungs. This may be performed from 
six to ten times upon each side. 

Photo. YIII. Stretch standing, trunk sideways bending. — The stretch 
standing, trunk sideways bending is taken from the stretch standing posi- 
tion, in which position the arms are extended parallel upward, with the 
fiuarers straightened. The head is extended and the chin retracted. The 
sideways bending is accomplished entirely by the lateral trunk muscles, the 
head and arms remaining in the stretch standing position. 
Vol. IV.— 21 



322 PHYSICAL DEVELOPMENT. 

Muscles : extensors of hands and arms, rotators of scapula, eccentric 
action of the muscles of the convex side of the bending body ; the muscles 
of tlie bent side remain nearly passive, as the bending is mostly produced 
by the weight of the body after the first motions are started upon the 
same side. Extension of the fingers : the extensor digitorum communis, 
interossei interni, adductor pollicis, and adductors of the fingers. Ex- 
tensors of the hand : extensor carpi radialis longior et brevior ; extensor carpi 
ulnaris ; extensor longus pollicis ; extensor digitorum communis ; extensor 
indices proprius ; extensor minimi digiti proprius. Extensors of the arms : 
triceps ; anconeus, also some of the extensor muscles of the hand ; extensor 
digitorum communis. Rotation of the scapula : serratus anticus major 
and trapezius. Flexion of the trunk : multifidus spinge and interspinales. 
Sideways bending : intertransversarii ; transversus abdominis ; quadratus 
lumborum ; obliquus abdominis iuternus et externus. 

The intention in assuming the stretch standing position is not only to 
stimulate the upper part of the thorax, but also to increase the effect of the 
trunk sideways bending, alternately performed, upon the liver, the portal 
system, the spleen, and the abdominal contents generally. This movement 
may be repeated from three to six times on each side. 

Photo. IX. Stretcli stride standing, trunk forward bending. — In the 
trunk bending forward the correct stretch stride standing position is first 
assumed. For the stretch standing position see Photo. VIII. In the stride 
the feet are separated about eighteen inches. In the bending forward the 
hands remain in a position parallel with the head. The bending is per- 
formed by the flexion of the entire spinal column. The knees must be 
extended, and the balance be maintained by a powerful action of the calf 
muscles. Bending the body forward sufficiently to touch the hands to the 
floor can be accomplished only after long practice. 

Muscles exercised : in assuming the stride standing position the muscles 
exercised are the adductors of the supporting thigh and the abductors of 
the limb that is moved sideways. The first motion, bending the trunk, is 
performed by the flexors of the abdomen. After the bending is started the 
weight of the body increases the motion, and (the stretching muscles) the 
extensors for the back as well as the ligaments keep the body from falling 
forward. 

Flexors of the abdomen (or the trunk) : 
r rectus abdominis; 
Direct, ■< obliquus abdominis externus et iuternus ; 
I psoas major et minor. 

{pectoralis major et minor ; 
serratus anticus major; 
transversalis abdominis. 
Extensors of the trunk : trapezius; rhomboideus; latissimus dorsi; ser- 
ratus posticus superior et inferior ; extensor dorsi communis ; multifidus 
spinse ; quadratus lumborum ; levatores costarum. 



P}T(')T(). X. 



VUnTO, XI, 




Half Stketch Walk, Standing Position. 



STRETCH Walk Standing, Tkunk Turning Posi- 
tion. 



PHOTO. XII. 



PHOTO. XIII. 






Yard AValk, Fall .-tandinc Positlin. 



Stretch Standing, Heels Rising, Knee 
Bending Position. 



PHYSICAL DEVELOPMEXT. 323 

Ligaments : fibrocartilagiues i nter vert eb rales; ligamentum longitiidinale 
posterius; ligamenta subflava; ligamenta interspinalia et ligamentum nuclise; 
ligamentum apicum ; ligamenta transversaria. 

The stretch standing position has been already described, but having 
this position in the trunk bending forward stretches the muscles and makes 
pressure upon the circulation of the blood-vessels of the spinal cord, and by 
the slow alternate flexion and extension the blood is forced into and out of 
the vessels of the brain, thereby removing the venous blood and replacing 
it with fresh arterial blood. This has a streuD-thenine: and stimulating 
effect upon the brain-substance and the spinal cord, as well as upon the 
entire nervous system to its finest ramifications. 

Photo. X. Half stretch walk, standing position. — In the half stretch 
M^alk, standing position, the left arm is extended forward and supinated, and 
the right arm extended and pronated downward and backward. The left 
knee is flexed, and a great portion of the weight of the body is thrown 
upon it, by which action the extensors of the left leg are put into very 
strong concentric exercise. The right leg is extended backward and 
abducted, and is assisted in maintaining this position by the ileo-femoral 
ligament. This position may be retained from one to two minutes. 

Muscles exercised : extensors of back, legs, and arms. Eight arm pro- 
nated and moved backward by latissimus dorsi, rhomboideus, trapezius 
(middle and inferior part). 

By taking this position any undue strain upon the abdominal organs is 
prevented. The intention of the exercise is to stimulate the back muscles 
as well as the circulation to the spinal cord. 

Photo. XL Stretch walk, standing, trunk turning position. — This posi- 
tion differs from the half stretch walk (Photo. X.) in both arms being ex- 
tended instead of one. The lower extremities are both in the same position 
as in Photo. X. In the turning the arms must remain parallel to each 
other, and, as the weight is supported entirely upon the flexed knee, the 
turning is confined to the upper part of the trunk. 

Muscles exercised : by the position, see Photo. X. ; by the turning, see 
Photo. VII. 

This position taken to its fullest extent has at the same time the strong- 
est influence upon the respiration, circulation, and digestion of any single 
exercise in gymnastics, and has a beneficial reaction upon the entire nervous 
system. 

Photo. XII. Yard walk, fall standing position. — This position differs 
from the half stretch M-alk (Plioto. X.) in the position of the arms, which 
are extended horizontally both in the same line. 

Muscles exercised : the deltoideus and infraspinatus lift the arms hori- 
zontally ; the scapulse are fixed backward by the rhomboideus and trapezius 
(middle part). For muscles exercised in the walk forward, fall standing 
position (extensors of back and legs), see Photos. X. and XL 

This extending and flexing the arms alternately in a horizontal plane 



324 PHYSICAL DEVELOPMENT. 

has an expanding influence upon the chest, stimulates the respiration, and 
develops the arm muscles. 

Photo. XIII. Stretch standing, heels rising, knee bending. — The arms 
are stretched up parallel, the fingers closed and extended, the shoulders 
back, the neck and back extended, the knees bent sideways and outwardly 
rotated, and the heels close and lifted. This exercise influences the exten- 
sor muscles of the body and expands the lungs, and is good for strengthen- 
ing the spine and the nervous system. For the muscles exercised, see 
figures describing arm stretching and heels rising. Knee bending, the 
flexors act in the bending, then the extensors resisting are brought into 
action and are mainly exercised ; these latter muscles are the gluteus 
maximus and the gluteus minimus (three glutei), pyriformis internus, semi- 
membranosus and semi-tendinosus, and abductor magnus. 

Physical Development in the Treatment of Disease and Deformity. — Most 
of the affections benefited by the movement cure are of the chronic type, 
and require for the most part the second or duplicated variety of exercises. 
In the majority of these diseases, too, what is required is to restore and 
develop the entire body : in other words, their cure involves the vital 
principle of physical culture, — the acquirement and preservation of health. 
In addition to this, in others it will be necessary to perform certain specific 
exercises intended to stimulate and restore directly the affected region or 
organ. These need not here be described in full, as they have already been 
given in more or less detail in other parts of this work. 

In considering the subject of movements in their particular application 
to children, the employment of such apparatus as dumb-bells, Indian clubs, 
chest-weights, rowing-machines, etc., must not be overlooked. Tlie length 
of this article, however, will not permit of their description in a proper 
manner, so that those interested are referred to the excellent writings of 
Maclaren, Sargent, Blakie, Ralfe, Ball, Dowd, Oswald, Schaible, and others. 
Xor must the subject of passive and active movements by means of the 
beautifully-constructed apparatus employed at Baden Baden and similar 
resorts be slighted. These systems possess a voluminous literature of 
their own, and are neither specially adapted for childhood and adolescence 
nor properly to be considered within the limits of this article. 

In conclusion, attention may again be directed to the tendency to de- 
velop some parts at the expense of others, — the lower extremities of runners, 
the back and forearms of rowing men, etc., — and to the necessity of in- 
sisting as far as possible upon the complete development of the body ; in 
other words, emphasizing the statement of Dr. Parkes that, when a single 
muscle or group of muscles is exercised to too great an extent, these after 
growing to a great size begin to waste, which does not seem to be the case 
when all the muscles of the body are exercised. 



MASSAGE. 

By WILLIAM A. EDWAEDS, M.D. 



Massage, from the French word masser, literally means kneading, but 
in its application of to-day it denotes the communication of motion to 
the tissues from an external source, in contradistinction to the various 
movements, Swedish, localized, and remedial gymnastics. The latter terms 
are used to designate motions of the entire limb or limbs or of the trunk 
through the joints. 

Historical. — The application of massage to medicine is of ancient date ; 
indeed, as Weiss and Ritterfeld tell us, documentary evidence shows that 
the Chinese recognized its importance three thousand years before our time, 
and that remarkable book of the Hindoos, the Susruta, contains descrip- 
tions of mechano-therapy ; the Brahmins continue even up to the present 
time the method that was in use thousands of years ago. The Chinese 
publications of centuries ago present illustrations which show clearly the 
correctness of the ideas of the Chinese physicians at that time concerning 
massage and medical gymnastics. Duhalde informs us that the schools 
then establislied have been maintained, until now they form part of the 
regular curriculum of the educated Chinese physician, and that it was 
probably from the Hindoos and Chinese that the Greeks and Romans 
obtained their information on masso-therapeutics. It was not until the 
internal disintegration of the Empire had commenced that Rome introduced 
the brutal exhibit of her circus sports in place of the more refined exercises 
learned from her Grecian neighbors ; and finally the Christianity of the 
Middle Ages, in abolishing all Roman customs, made no exception of 
mechano-therapy, which consequently fell into disuse until about 1680, when 
Borelli called attention to its peculiar virtues. In 1740, Fuller, in England, 
published a little work which attracted much attention, and which appears 
to have been the turning-point in a revival of the popularity of massage, 
as the works of Bdrner and Gehricke (1748) appeared in rapid succession, 
followed in 1781 by that of Clement Joseph Tissot, later by those of Bar- 
thez and the two Webers, and by John Pugh's (1794) treatise on the science 
of muscular action, which in turn was folloAved by Barclay's Edinburgh 
work (1808), "■ The Muscular Motion of the Human Body," which Schreiber 

325 



326 MASSAGE. 

(1887) considers worthy of special commendation. Balfour added his testi- 
mony in 1819, and Pravaz in 1827 ; but the greatest advance was made by 
Blache in 1855, and by Ling, whose work at the Central Institute of 
Gymnastics at Stockholm extended from 1806 until his death in 1839. 

Schreiber tells us that the number of magazine articles and pamphlets 
from all sources up to 1874 ranged from one to four a year, increasing 
in 1879 to nineteen publications in various languages: this increase 
demonstrates the general interest in the subject that was awakening in the 
entire medical world. Most of the larger cities have erected institutes for 
sanitary gymnastics, and in the last few years it has won for itself a place 
in all the standard works on therapeutics and general medicine. 

Effects. — The effects of massage or mechanical movements may be 
properly considered under two subdivisions, (a) primary and (6) secondary. 
Under the former we attempt the removal of exudates, extravasations, 
vegetations, and adhesions ; under the latter, stimulation of the muscular 
and nervous system by increasing the circulation and setting on foot cell- 
changes and metamorphosis of tissue, and furthermore directly affecting the 
process of general nutrition. The eflTect of centripetal stroking of the 
body is to increase at once the rate of flow of the lymphatic and the venous 
circulation in the part ; this has been demonstrated beyond peradventure 
by Von Mosengeil's well-known experiments upon the effect of massage 
in causing absorption from about the joints. This observer injected 
finely-levigated black India-ink into the joints of rabbits, and those joints 
which were subjected to massage showed a progressive decrease in size, 
while the others remained large. After death the India-ink was found, in 
those limbs which had been manipulated, scattered through the thigh and as 
numerous foci in the areolar tissue. 

Classification. — We adopt the classification of Mezger, Mdiich is gener- 
ally accepted to-day,— viz. : 1, effleurage (stroking) ; 2, frictions (friction) ; 3, 
petrissage (kneading) ; 4, tapotement (percussion). The first manipulation 
consists in stroking with the palm of the hand or its radial border, or 
with the tips of the fingers, or with the thumb alone, and the force applied 
may be the gentlest possible or the heaviest pressure made by reinforcing 
the operating hand with the other laid on top of it. Where deep effect is 
desired, as the removal of exudations in the tendons or the intermuscular 
tissue, the thumb or several fingers are used, the tips being held nearly per- 
pendicular to the surface, and the degree of penetration is dependent upon 
the amount of pressure exerted. When working in bony regions, only mod- 
erate pressure must be used ; when concerned with large muscular masses, 
the fleshy cushions of the palm of the hand must be brought into requisi- 
tion, and the patient so placed that the masseur can be aided by the weight 
of the upper part of his trunk in giving force to the stroke. As a rule, 
the strokes are to be made centripetally, — that is, towards the central organ 
of the circulation ; in certain rare cases this rule may be disregarded, and 
the direction of the stroke may be centrifugal. 



MASSAGE. 327 

Friction cousists in the use of tlie thumbs or the tips of the fingers in 
strong, forcible circular rubbings, followed by centripetal stroking. The 
object of these manipulations is to act upon deposits in diseased parts in 
such a manner as to distribute them among healthy tissues, and, inasmuch 
as pathological deposits may exist in any tissue, we can formulate no gen- 
eral rule for the direction which the frictions may take, but it should rather 
be our aim to reach sound tissue, and consequently the friction may be 
centrifugal if the healthy parts lie in that direction. 

Petrissage, or kneading, is performed with the tips of the thumbs or 
with the index finger and the thumb, and consists in picking up a muscle 
or other tissue and subjecting it to firm pressure, either by the thumbs and 
fingers or by the fingers and the deuse tissue that may underlie it. 

Tapotemeut, or percussion, is usually divided into four sections: 1st. 
Clapping with the palm of the hand or with an instrument especially con- 
structed for the purpose. 2d. Hacking, which is performed with the ulnar 
border of the hand or with the extended fingers, depending upon the im- 
pression desired to be created ; with the fingers the motion is made from 
the wrist-joint, Avith the edge of the hand it is either from the elbow- or 
from the shoulder-joint. 3d. Punctuation, which is performed with the 
tips of the fingers, and is usually applied upon the head or upon the prse- 
cordia. 4th. Beating with the clinched hand ; usually applied over the 
thick muscles of the thigh. 

Local Massage. — Having considered the special forms of massage, 
it will be well to review its application to the various parts of the body, 
which we will term local massage. 

Massage of the leg commences with stroking from the foot to the hip, 
and then friction from the interosseous muscles upward, followed by stroking, 
which in turn is followed by kneading, and the treatment of the limb is 
completed by "hacking over the muscular parts. The arm receives a similar 
treatment, which is best applied in the semi-flexed position. 

The Chest. — Here again we commence by stroking with the hands on 
each side of the sternum, manipulating upward and outward with circular 
movements. The praecordia is to receive circular punctuation : too much 
strength must not be used, and the treatment of this region may be ter- 
minated by hacking and clapping. The back should receive much care, and 
is to be treated by downward stroking from the base of the skull to the 
sacrum, taking care to avoid the spinous processes of the vertebrse ; this 
is to be followed by friction with the tips of the fingers in the same general 
direction, making the movement more lateral, so as to include the postero- 
lateral aspect of the trunk. Then spread the hands over the back and 
knead with the thumbs between the vertebrae, and administer hacking 
up and down the back several times, — some authorities say ten times, but 
this would certainly be more than a child could stand. It is well to finish 
by stroking and clapping, particularly the latter, and especially on the 
rigrht side. 



328 MASSAGE. 

The Abdomen. — The patient lying upon the back, with the legs flexed on 
the thighs and the thighs on the abdomen, — to secure perfect relaxation, 
which is essential, — the masseur commences on the right side by spreading 
the right hand over the abdomen and pressing with the heel of the hand 
and the fingers alternately ; this manipulation is to be carried out in the 
direction of the transverse colon. Kneading is next applied by the tips 
of the fingers. 

The head is best treated by stroking, friction, hacking, and shaking. 
The first is applied principally to the forehead : with " the thumbs between 
the eyebrows, the stroke is to be carried firmly over the temples to the ears, 
both thumbs working together." Friction of the entire head with the palm 
of the hand, hacking with both hands, making circles over the head in all 
directions, and gentle shaking by clasping the forehead with both hands and 
shaking the head carefully and deliberately, will, as a rule, be the best 
method of procedure. 

In massage of the face only two motions are used, — stroking and fric- 
tion. "With the index finger in the mouth, the thumbs stroke the muscles 
of the cheek, and by the thumb and the index finger the muscles are picked 
up and subjected to rotatory movements. 

Massage of the Throat and Neck. — Von Gerst advises that the patient 
be " stripped to the middle of the chest, and stand with head thrown back 
and shoulders relaxed ; deep, full, and regular breathing by the patient is 
essential, else the return venous circulation will be impeded. Each stroke 
consists of three parts. First, the open hands, with the palms upward, are 
placed, with their ulnar borders in the right and left cervical fossae, between 
the head and the neck, so that the tip of the little finger and the last joint 
of the ring finger shall rest upon the mastoid process behind the ear, and 
the ball of the little finger under the horizontal branch of the lower jaw. 
A centripetal movement is now begun with the ulnar borders of the palms 
thus placed in the superior cervical region, and is performed as follows. 
AMiile the ulnar border is moving towards the middle of the neck, both 
hands perform a rotation on their long axes, so that the radial border turns 
upward and inward towards the head and finally reaches the position first 
occupied by the ulnar border, and thus the entire palm has come in contact 
with the neck and is now employed in giving the stroking." A slight de- 
gree of pressure is to be exerted by the balls of the thumb upon the jugular 
veins, and by the palmar surface of the fingers upon the venous and 
lymphatic vessels along the lateral cervical regions. At the supraclavicular 
fossa the hand again turns upon its long axis, and the radial border of the 
palm once more comes into use. The lateral cornua of the hyoid bone 
and the larynx are to be avoided ; pressure on either produces pain and 
inclination to cough. 

Movements. — The various Swedish movements are peculiarly applicable 
to the growing child, and, when judiciously used, will do much to produce 
a symmetrical growth, preserve health, and correct vicious tendencies. 



MASSAGE. 329 

The Applicatiox of Massage and Swedish ]\IovE:\iEyTS ix the 
Treatment of Disease, — We will first consider the conditions which 
demand neck-massage, as in this region, owing to tlie numerous superficial 
veins and the distribution of the carotid arteries, we can act almost directly 
upon both circulations. Indeed, massage in this region has been compared 
to copious bloodletting without its disadvantages ; consequently it is most 
advantao;eous in cono-ested conditions of the brain and its membranes. 
Being a rapid method of depletion, it is efficacious in sunstroke, also in 
headache and hemicmnia when these are of the congested type ; but when 
the latter occurs in weak, anaemic, nervous children, massage of the neck is 
useless ; our efforts then would better be directed to manipulation of the 
scalp, forehead, and temple, bearing in mind, however, that in these chil- 
dren massage in this region is apt to produce hypnotism. Vretlind believes 
that in many instances hemicrania is due to chronic myositis, in which 
case, of course, the muscles must be carefully manipulated to remove the 
indurations. Walter Johnson goes even further, and says that the necks 
of nearly all his patients who had suffered for any length of time from 
head-affections were swollen and indurated, with, probably, enlarged and 
swollen glands in the neighborhood. 

Massage is said to have been used with the most gratifying results in 
the so-called wasting diseases of children. 

Peripheral neuralgias which are not dependent upon central nervous 
disease or deep-seated pressure (tumors) are peculiarly amenable to the 
effects of massage, — percussion or kneading. Sciatica is often speedily 
relieved, particularly if it be rheumatic and come under treatment before 
alteration has taken place in the sheath or the neurilemma. 

The so-called sensitive points met with in different parts of the body in 
nervous girls at or about adolescence are often entirely removed by massage. 
These points when located over the spinous processes of the vertebrae are 
often responsible for hysterical outbursts. 

Cramp, when peripheral and due to over-use, over-tension, or irritation 
of the nerves, is to be treated by percussion, kneading, and strong stroking 
of the muscle or group of muscles affected. 

Chorea. — If the child is violent, it should be held supine upon a mat- 
tress for from ten to fifteen minutes, while the masseur applies gentle 
stroking with the palm of the hand over the entire body ; the time occu- 
pied in this application is to be rapidly increased to an hour and to be 
repeated every three or four days. In a shoi't time regular passive move- 
ments are to be added to the treatment, care being taken to overcome 
the tension of the antagonistic muscles, so that within eight or ten days 
the child can take a few voluntary active muscular movements. Within 
the next week gymnastic exercises are introduced, Avhich must be of the 
simplest form, and are to be combined with simple voluntary movements 
of the limbs and trunk. It is "well to have the patient imitate the move- 
ments of the masseur, in order to exercise his will-power. Rhythmic 



330 MASSAGE. 

movements timed by music are of inestimable benefit for the exercise of the 
child's will and brain. The case is apt to improve up to a certain point 
and then reach a stationary period, in that event sorely taxing the phy- 
sician's skill ; but a happy termination will usually be brought about by 
kindness, persuasion, aud encouragement. Blache states that of one hun- 
dred and eight cases of chorea in childhood treated as above recorded not 
one relapsed. 

It is not our province in this article to refer to the benefits to be derived 
from massage in the peripheral palsies of motor nerves, in lead-poisoning, 
or in the local anaesthesias ; but we desire to call special attention to its use 
in anterior poliomyelitis, — infantile spinal jjaixilysis. It must, of course, be 
applied only after the acute manifestations of the disease have subsided and 
all evidences of irritation in the central nervous system have passed away : 
then, and then only, will massage be of benefit ; furthermore, after massage 
has been persisted in for a time, the muscles will respond to electric stim- 
ulation. Von Mosengeil mentions a case in which at the expiration of four 
months electric excitability was completely restored. Norstrom adds his 
testimony to the efficacy of the method, but Murrell considers that some of 
the improvement is due to the retrogressive character of the disease. 

Post-diphtheritiG paralyses, as Kellgreu tells us, are often at once and 
permanently relieved by manipulation ; he records the case of a girl under 
treatment from June 23 to August 16, eighteen seances in all, who was 
discharged cured and in whom no relapse occurred. 

Angina pectoris has often been relieved by vigorous stroking and knead- 
ing over the heart. Miihlberger records the case of a young man in whom 
the relief was marked, the severity of the attacks being much lessened. 

Abdominal massage is of benefit in many cases, as in this way we can 
act upon the circulation of the blood and lymph and stimulate the secre- 
tions and excretions of the entire gastro-intestinal tract, to say nothing of 
its effect upon effusions or new growths or faecal accumulations. Hence, as 
Lee says, abdominal massage is indicated in acute or chronic gastric and 
intestinal catarrhs, dyspepsias, cardialgia, dilatation of the stomach, intes- 
tinal obstruction, tympanites when not dependent upon inflammatory action, 
ascites, and, finally, all the sequelee of peritoneal inflammation, as peritoneal 
or extra-peritoneal exudations or adhesions, provided, of course, that all 
sio-ns of inflammation have subsided. In habitual constipation, combined 
with pelvic gymnastics its effect is most happy ; indeed, even when the 
accumulation is so excessive that occlusion is threatened, it is often possible 
by very gentle massage to move the hardened fsecal mass onward towards 
the sigmoid flexure so that it may be reached and softened by injections. 

The liver and spleen are directly accessible to manipulation when they 
are enlarged, and even when they are normal in size they may be indirectly 
affected by massage : hence it is indicated in hepatic congestion, enlarge- 
ment, or jaundice, and in splenic engorgement ; gymnastic exercises should 
be added to the treatment. 



MASSAGE. 331 

In the anseniatoses, as chlorosis and aneemia, general massage of the whole 
body, in combination with the usual plan of treatment in such cases, will 
often hasten the return of the blood to normal. We have already called 
attention to the effect of massage upon the blood- and lymph-circulatiou : 
its effect on superficial oedema will likewise be most happy, whether the 
oedema be a manifestation of a general disease or be due to local obstruction. 
Massage is peculiarly grateful to those patients who present oedema of the 
lower extremities, and is particularly to be recommended in the oedema of 
scarlatina, where it not only acts directly upon the circulation of the parts, 
but also assists in restoring the skin to the normal. 

In diseases of the heart, massage is capable of affording much relief. 
Gendriu formulated the apt expression that " massage constitutes a sort of 
accessory venous heart." 

Several careful observers demonstrate beyond cpiestion that massage 
causes an elevation in the surface-temperature. For example. Mills has 
recorded observations on the general and axillary temperature in a girl nine 
years of age who had partial* paralysis of the right arm and both legs 
following scarlet fever ; the temperature showed the following changes : 

Before Treatment. After Treatment. 
99.5° F. 100° F. 

99.3° F. 100° F. 

99° F. 99.5° F. 

99° F. 99° F. 

99° F. 99.5° F. 

Weir Mitchell is even more decided upon this point, and remarks that he 
has frequently seen the strangely cold limbs of children suflPeriug from 
infantile paralysis gain from 6° to 10° F. during an hour's massage. 



REFEKENCES. 

In the preparation of this paper the writer has made free use of the following authorities : 

Joseph Schreiber, Manual of Treatment by Massage and Methodical Muscle-Exercise, 
1887. 

William Murrell, Masso-Therapeutics, 4th ed., 1889. 

Benjamin Lee, Tracts on Massage, 1887. 

Ostrom, Massage and the Swedish Movements, 1890. 

C. K. Mills, Massage, etc., in Nervous Affections, Medical and Surgical Reporter, 
Philadelphia, October, 1878, p. 283. 

Goodhart, Treatment of Acute Chorea, etc.. Lancet, August 5, 1882. 

Douglas Graham, Massage, etc., 1889. 

Mary Putnam Jacobi, Cold Packs and Massage in Anasmia, Archives of Medicine, 1880, 
iv. 12, pp. 57, 163. 

Gillette, Massage in Intussusception, New York Medical Journal, September, 1882. 

W. W. Keen, Polyclinic, Philadelphia, February 15, 1885, vol. ii. jSTo. 8. 

Reibmayr, Trans, by Lee, Philadelphia, 1885. 

S. Weir Mitchell, Fat and Blood, and How to Make them. 

George H. Taylor, The Movement Cure, 1888. 

M. Granville, Nerve-Vibration as a Therapeutic Agent, Lancet, 1882, i. No. xxiii. 



PROPHYLAXIS OF DISEASE IN CHILDREN. 

By J. WELLINGTON BYEES, M.D. 



Peophylaxis may be designated as a series of methods or procedures 
whereby contagious disease is restricted and prevented by suppressing or 
removing its predisposing conditions and destroying or modifying its 
exciting causes. 

Viewing the subject in the light of this "definition, it will be seen that 
preventive medicine is largely dependent upon a knowledge of the etiology 
of disease, and that its sphere is precursory. In order, therefore, to obtain 
a satisfactory understanding of its principles and methods, such as may be 
peculiarly applicable to contagion among children, it will be necessary to 
examine into those circumstances and to discuss those influences which are 
ordinarily presumed either to favor or to retard the origin, the development, 
and the distribution of disease. 

Observation shows very generally that the conditions w^hich usually 
constitute human environment, including such factors as air, water, food, 
clothing, habitation, climate, and telluric influences, have a constant and 
powerful effect in shaping the type and advent of morbid phenomena, and 
that they often furnish the means by which the immediate or exciting 
causes of disease reach, invade, and are eliminated from the body. Hence 
the whole system of prophylaxis purposes to understand these conditions 
and to take such advantage of them as will control or destroy their morbific 
agencies and influences. While it is true that investigations with etiologi- 
cal data are highly essential and conducive to a philosophical or scientific 
interpretation and practice of preventive methods, still it must not be con- 
cluded that its progress in the past or its prospect for the future has been or 
is solely contingent upon the exact amount of information possessed con- 
cerning the causation of the disease, since there are numerous and valu- 
able facts associated with its history which are not dependent upon these 
features for their utility. Indeed, experience pretty clearly demonstrates 
that it is eminently possible to achieve a very eflicieut system of pre- 
venting disease with little or no knowledge of its exciting causes. Many 
of the practices now in vogue were originated long before the era of the 
germ theory ; still they are now none the less reliable. A number of dis- 
orders corroborate this and illustrate the methods of prevention in a high 
332 



PROPHYLAXIS OF DISEASE IN CHILDREN. 333 

degree, though their causes are quite unknown. This is exemplified in all 
the acute exanthemata and in diphtheria, each of which shows unmistakable 
evidences of amenability to isolation and disinfection, yet the personality 
of their specific agents is conjectural. Therefore it must never be concluded 
that for prophylaxis to be efficient the causes of disease must be known, 
since experience teaches the contrary. 

As set forth in the definition, there are two general methods employed 
in attempting to restrict and prevent the spread of contagious disease. The 
first of these is preparatory and defensive, and treats of those conditions, 
externally in the media and internally in the body, which invite or predis- 
pose to the occurrence of morbidity or which foster and sustain its actual 
exciting causes. The second class in contradistinction to this is aggressive 
and destructive, and purposes to seek out, attack, and kill the specific germs 
of contagious disease or to render their surroundings so inimical that they 
will perish. This latter method constitutes disinfection. As preliminary to 
a consideration of these two divisions of the subject, it must be observed, 
however, that the disorders especially referred to here as preventable and 
avoidable have the common features that they are transmissible mediately 
or immediately from sick to seemingly well though susceptible persons, and 
that they are each presumably due to or caused by a specific germ or con- 
tagion, which is, as a rule, a living unicellular vegetable micro-organism of 
the general class bacteria. Bearing this in mind will better enable us to 
perceive the scope and plan of prophylaxis. All zymotic diseases, while 
not originating in pecidiar environment, so far as we are now aware, yet 
are its inevitable outcome. In other words, there must always be suscep- 
tibility upon the part of the infected subject and pathogenicity upon the part 
of the germ, before disease can arise and manifest itself. If there should 
be anything in the external media or in the internal conditions of the body 
calculated to hinder or frustrate the operations of the contagion, and it fails 
to germinate or reproduce, the individual escapes. Hence there must always 
be a certain amount of co-operation among all the factors concerned in dis- 
ease-processes in order for the disease to exist. As has been stated, these 
conditions relate to the exciting cause so as to foster and assist it, or to the 
body so as to debilitate it and render it vulnerable or susceptible to patho- 
genic agents. A satisfactory understanding of how these influences act to 
produce these results is obtainable by an investigation of the relations of 
the two factors of predisposing conditions and exciting causes. 

Before proceeding to a discussion of these, however, I deem it necessary 
by way of parenthesis to mention the misconceptions which have arisen 
in regard to the use of the terms predisposing conditions and exciting 
causes. It has been customary, under the older notions of disease-etiology, 
to employ the latter of these when describing circumstances antecedent 
and related to its occurrence. In the light of recent developments this 
is both wrong and illogical, and should be dispensed with, from the fact 
that we now know full well that none of the agencies or conditions usually 



334 PROPHYLAXIS OF DISEASE IN CHILDREN. 

embraced bv these phrases are at all capable of generating or acting as a 
cause of specific disease. 

Everything that happens must either have an adequate cause — that is, an 
agent — or be spontaneous; still, there is a material and broad difference, when 
speaking of contagious disease, between substances and conditions, between 
agents and agencies. The first are definite, an entity ; the latter, a state or 
relation. To illustrate practically, take the instance of erysipelas following 
a wound. Here the wound acts as a condition which renders the entrance 
of the erysipelatous virus possible, and without which it could not enter 
or progress, yet the wound is in no sense a cause of erysipelatous disease 
and would never under any circumstances originate or produce it in the 
absence of the specific poison. It is a contributory or predisposing condi- 
tion, which assists the virus, and not a cause of the disease. This is a 
distinction seldom insisted upon in etiology heretofore, though, as a means 
of a clear idea of the causation of pathogenesis, such as will be of service 
in antagonizing its advances and encroachments, its propriety cannot be 
gainsaid. In fact, it is fundamental to quite a number of the methods 
pursued in prophylaxis, and they owe their practicability and efficiency to 
the fact that disease-conditions and disease-causes are distinct from each 
other. It is by studying and classifying these separate influences that 
we learn to modify and remove them and establish a scientific basis for 
preventive medicine. 

As has been remarked, predisposing conditions may be made to include 
all those external states which determine the mode of life, propagation, and 
distribution of disease-germs outside the body, and also those internal in- 
fluences which alter or control the resistance of the body to their invasion. 
With regard to the conditions which chiefly influence the body so as to 
render it susceptible to disease-agents, there are two kinds, the internal 
and the external, some of which are avoidable and others inevitable. It 
does not lie within the purpose of this article to enter into details as to 
how and why these conditions produce their effects, or how and why the 
removal of them gives exemption and immunity. We must accept them 
as facts fully corroborated by a long series of reliable experience. As to 
the rationale and mechanism of the physiological processes that lead to 
protection from disease, there are many vastly interesting phenomena which 
recent advances in bacteriology and chemistry have brought forward. The 
germ theory of disease, together with the labors of Metschnikoff" and his 
coadjutors in the phagocytic actions of cells, opens up a new and luminous 
prospect for all medicine, and ere long we shall possibly be equipped with 
the facilities for knowing precisely and seeing actually the processes of 
immunity and protection going on. Undoubtedly these, in addition to 
the experiments now being conducted throughout the world by means of 
attenuated viruses inoculated for the purpose of preventing and anticipating 
infectious disease, foreshadow great possibilities for all measures of prophy- 
laxis. Again, the introduction for similar purposes of ptomaines, leuco- 



PROPHYLAXIS OF DISEASE IN CHILDEEN. 335 

maines, and such other drugs and synthetical chemicals as have analogous 
molecular composition or constitution to the specific poisons of the pathogenic 
germs, will eventually place preventive medicine in the foremost rank of 
beneficent science. 

Among the external conditions that produce tendencies towards disease 
are foul air, damp soil, filthy habitations, poverty of food and clothing, 
defective sewerage, and the like. All of these, by lowering the vital forces 
and depressing the systemic functions, induce a condition of susceptibility 
to morbid agents. They prepare the soil for disease-germs and create pro- 
clivities favoring their development. The ancients, while knowing nothing 
of the final vital reactions of the tissues, or how they operated to protect 
the system, recognized the great importance of hygiene and sanitation in 
furthering these events and controlling and warding off the approaches of 
disease. Hence the Greeks and Romans never failed to inculcate regu- 
lations pertaining to hygiene. Moses, the law-giver, laid down a sanitary 
code, with severe penalties attached for infringement, and gave directions 
for the disinfection of persons, places, and things, so thorough and effective 
that even this advanced age can find little room for improvement. There- 
fore there is nothing new in the statement that health protects itself and is 
the means of its own defence. 

Recent developments in histology and bacteriology show that, while the 
cells of the body possess the ordinary functions of growth, reproduction, 
and assimilation, they have in addition aptitudes or inherent powers for 
discriminating between natural and foreign substances in the economy, and 
that they seize upon, devour, and cast off the latter in a most marvellous 
and perfect manner. In order to do this, however, and keep the system 
protected from the invasion of noxious substances, the cells must be sus- 
tained at the normal standard of healthy action, their pabulum and 
stimuli the best, such as hygienic influences are capable of furnishing, 
since if they be depressed by the presence of predisposing conditions 
they are unfit to cope with the enemy the micro-organism, and they 
23erish. Therefore, since the vital organism is qualified to protect itself, 
it should be assisted by all the means at hand, and everything removed 
that tends to hinder or cripple its efforts. The experiments recently made 
by Roger and Charrin confirm this in a remarkable degree : they find 
that, even when the serum of the blood is impoverished, it alone may de- 
termine susceptibility and render the entrance of the germ possible, bacteria 
being far less active and virulent in it the nearer it approaches the standard 
of healthy blood. When we recall the very general prevalence of germs, 
the wisdom and necessity of exemption and protection being dependent upon 
something outside from and superior to human knowledge and precautions 
become obvious. 

Among the internal states or conditions which create liability to disease- 
agents may be mentioned age, sex, nation, race, certain diseases and drugs. 
As to the exact nature and conformations of the tissues which permit the 



336 PEOPHYLAXIS OF DISEASE IN CHILDREN. 

invasions of the morbific substances, we know these principally by the 
result, — susceptibility. It is highly probable, however, that this subjective 
condition is largely influenced by circumstances related to the nutrition of 
the body as a whole and the finer cells of the tissues in particular, and it is 
only when they depart from this standard that the influence of the patho- 
o-enic germ is capable of doing harm. From the statements already made 
in connection with the theory of the cellular warfare which goes on between 
the disease-germ and the cells of the organism, we see that disease is 
kept off" or prevented by an active and discriminating process of the body, 
and that susceptibility is the absence of these resources or a failure to exert 
them. As yet, we are not in a position to specify exactly what the germ 
must and must not find in order successfully to invade, multiply in, and 
set up disease in the body. We know in a general way that there must 
be a condition of susceptibility, and that the germ must meet with a com- 
bination of circumstances favorable to its growth and development, among 
which may be mentioned suitable pabulum and proper and agreeable 
temperature, and that it must nowhere encounter any substances or con- 
ditions which either check or injure it. It is known that exciting causes 
can act only upon systems predisposed towards their reception, but whether 
this liability is chemical, mechanical, or vital, in addition to what has been 
said, we are not as yet prepared to state. Susceptibility is primarily weak- 
ness, though there are doubtless other influences which alter and lessen the 
system's natural protective powers, in kind as well as in degree. 

Hence, when debility is present, howsoever induced, whether by external 
conditions of environment or by reason of peculiar internal states, the system 
is lowered and rendered incapable of contending in a successful and physio- 
logical manner with the pathogenic intruders, and the body succumbs to 
disease. Therefore, if we wish successfully to assist and protect the system, 
we should remove in advance all those conditions and influences which have 
a tendency either to favor the exciting causes or to depress the systemic 
functions of the body. Sanitation fortifies the normal actions and removes 
all depressing conditions, while disinfection modifies and destroys the 
exciting causes. 

Thus having briefly outlined the necessities, reasons, and philosophy 
of prophylaxis, we will now pass to an enumeration of the methods and 
details by which these objects may be accomplished. 

Whenever there is reason to suppose that an outbreak of infectious dis- 
ease is imminent, there should be a thorough overhauling of everything 
calculated to facilitate its approach or protract its stay. In all these under- 
takings there should be system and regularity, the prime object being always 
kept in view. The first case or cases of disease should be at once isolated, 
and all visitors and susceptible members of the family warned and excluded 
from the apartments or premises. All sources of decaying matter should 
be at once freely sprinkled with chloride of lime, or wet with a solution of 
the same, and removed. There should be free ventilation and absolute 



PROPHYLAXIS OF DISEASE IN CHILDREN. 337 

cleanliness as far as is possible. When the case subsides, all bedding, 
clothing, furniture, rooms, and persons should be thoroughly submitted to 
such processes of disinfection as will best eradicate every vestige of con- 
tagious matter. The belief that certain germs are the efficient causes of con- 
tagious disease has led to the employment of a great number of experiments 
for the destruction of bacteria by means of heat and chemical substances, 
and thereby the doctrine of disinfection has been established and developed. 
Some diseases are far more contagious than others, measles and whooping- 
cough being feebly so, and scarlet fever and diphtheria very much so. 

By a disinfectant is meant, in the language of the definition given by 
the American Public Health Association, " any agent capable of destroying 
the infectious agency of infectious material." Most of our kno\vledge con- 
cerning the efficacy of chemical disinfectants is drawn from their influences 
upon putrefying matter of organic origin, and it has been found that what 
will arrest putrefaction will also destroy the germs of disease, and vice versa. 
Only a few diseases are now considered to be directly concerned with filth. 
Cleanliness of the surroundings has little or nothing to do with small-pox, 
measles, scarlet fever, or whooping-cough, and no amount of sanitary effort 
will influence them in the least. Such diseases, however, as consumption, 
diphtheria, the various dysenteries and diarrhoeas, and cholera infantum, 
are directly concerned -svith filth in relation to water-supply, drainage, and 
sewerage. (Billings.) 

With regard to the mode through which disinfectants exert their in- 
fluence, several explanations have been offered. Some are thought to act 
by oxidization, others by their property of coagulating albumen, and still 
others in a way either entirely unknown or but imperfectly understood. 
What is a disinfectant for one disease of this character, however, is a dis- 
infectant for all, and it will only be necessary to review a few of the most 
reliable and important ones. 

Generally, in the absence of spores (and no human disease has any, so 
far as we know), a heat of 250° F,, sulphur dioxide in fumes, and solutions 
of the bichloride of mercury will destroy all pathogenic germs. A number 
of disinfectants are known to evolve oxygen freely, and are thought to 
hasten in this manner the disintegration of the noxious matters. 

In each particular disease there is always some peculiar or special por- 
tion of the body involved which is occupied by and reproduces the exciting 
causes of infection. It is to these parts that we must always first direct 
our attention when beginning to disinfect for the disease. Fortunately 
for prophylaxis, the exact location of the centres for breeding is known in 
quite a number of diseases, and we can attack these seats directly. In all 
the exanthemata this is the case, and in them it is the skin and the mucousj 
membranes which should receive the most attention ; while in typhoid fever 
and cholera it is the discharge from the bowels, and possibly from the kid- 
neys also, which we must particularly attend to. 

For personal disinfection, Labarraque's solution, diluted with twenty 
Vol. IV.— 22 



338 PROPHYLAXIS or DISEASE IN CHILDREN. 

parts of water, is suitable for washing and bathing the body. A weak 
carbolic solution, or a one-per-cent. solution of chloride of lime, will 
also be found efficient for the same purposes. Oily disinfectant inunction 
for the skin is one of the best methods of preventing the detachment of 
epithelia and pus, and should be used from the commencement of measles, 
small-pox, scarlet fever, and chicken-pox. It is found better and more 
agreeable when mixed with camphorated olive oil or with carbolic acid and 
olive oil. The throat and fauces in these diseases should also be washed 
with Condy's fluid or a weak solution of sulphurous acid. All discharges 
from the nose, eyes, and mouth should be received upon rags and imme- 
diately burned, or, if upon towels and handkerchiefs, these should be put 
in a solution of chloride of lime. The stools should be disinfected by a 
solution of bichloride of mercury, one-half ounce to the gallon of water, 
and all clothing treated by placing it in boiling water to which have been 
added two ounces of chloride of lime for each gallon. With regard to the 
disinfection of the apartments, furniture, and hangings, an observance of 
the directions in the general remarks that are to follow will be amply 
sufficient for all purposes. 

Heat. — Extremes of temperature have long been known to be disas- 
trous to animal and vegetable life, and are doubtless among the most efficient 
and satisfactory agencies that can be employed for disinfection. Of course 
it is not necessary to say that fire will destroy the principles of infection, 
since it is complete combustion. Heat in particular has a powerful and 
constant effect upon all albuminoid substances, both in coagulating and in 
desiccating. It is undoubtedly the best means of disinfecting bulky mate- 
rial, such as bedding, curtains, and clothing, and, if they be properly ex- 
posed to its action, all the contained life or contagion will certainly be 
destroyed. Heat is employed as a disinfectant in several ways, among 
which may be mentioned dry, moist or boiling, and steam heat. Drs. Par- 
sons and Klein have made numerous and elaborate experiments both on the 
degrees of heat and on the time necessary for disinfection. The results of 
their investigation show that dry heat is best adapted to the usual purposes 
of disinfection. Ordinarily this kind of heat can be supplied by a common 
laundry drying-closet or a baker's oven, and will be sufficiently powerful to 
destroy all contagion unaccompanied by spores. Dry heat has one principal 
objection, however : it penetrates bulky and badly-conducting substances 
very slowly, and the time usually allotted for the destruction of germs is far 
too short for it to be effective. Hence if the drying-closet or oven be used 
the articles should remain in it at least four hours, and the temperature 
should not be below 200° or 225° F., the latter being much better. With 
respect to the amount of heat that can be borne by ordinary fabrics, scorch- 
ing is said to occur at different temperatures in different materials. White 
woollens are always soonest affected, and should be carefully watched. To 
avoid these bad effects in them, the temperature should never exceed 250° 
F. ; and even this may in a majority of cases be too much for the finest wool- 



PROPHYLAXIS OF DISEASE IN CHILDREN. 



339 



lens. Dry heat is generally applicable to all that class of goods which can 
be boiled, and is said to be materially aided in penetration by the addition 
of a certain amount of moisture, though the moisture is of no assistance in 
facilitating the destruction of the germs. 

Dr. Henry has been successful in destroying the infective principle of 
scarlet fever, contained in clothing, by means of a dry heat of only 140° F. 
kept up for three hours. Most authorities, however, recommend a temper- 
ature of at least 225° F, for all kinds of exanthematous disease, such as 
small-pox, measles, chicken-pox, and the like. Sternberg's investigations 
demonstrate that the various germs perish at the following temperatures : 



Typhoid bacillus 132.8° F. 

Anthrax bacillus 129.2° F. 

Pneumococcus 136.4° F. 

Tuberculosis bacillus . . . 212° F. 



Cholera bacteria (Koch) . , 125.6° F. 
Micrococcus Pasteurii . . . 140° F. 
Staphylococcus p. aureus . 136.4° F. 



Koch has found that bacteria in general, free from spores, cannot resist 
a temperature of 212° F. for many minutes, and that if it is continued for 
an hour and a half they invariably perish. 

As to the action and results of moist heat or boiling as a disinfectant, 
experiences are not very satisfactory. Still, if the boiling be kept up for 
several hours, and a little carbolic acid, or chloride of lime or of zinc, be 
added to the water, the results can be relied upon as effective. Should 
there be any doubt about the destraction of the germ when lodged in 
clothing or other articles of similar character, we should not hesitate to 
employ the highest dry heat compatible with the safety of the goods. The 
finest fabrics will withstand for a reasonable time an elevation of 225° F., 
and linens, cottons, and woollens may be trusted to it without the appre- 
hension of any injury or danger. Two hours of dry heat such as has been 
described will be amply sufficient, and no evil consequence will follow either 
to the safety of the goods or in the form of disease. 

Steam is considered to be a rapid and pow^erful disinfectant, experience 
showing pretty conclusively that at 212° F. it will destroy all contagion, 
and the complete penetration by steam for five minutes is found capable of 
thoroughly disinfecting. Koch, Parsons, Klein, and Loefler all are agreed 
upon this particular. Steam penetrates far more rapidly than dry heat, and 
is much more destructive, in the time occupied, to all germs. A pressure 
of twenty-five pounds is said to assist materially in its destructive action. 

Chemical Disinfectants. — These are employed in the form of gases, 
liquids, and solids. 

Gaseous substances are employed principally for aerial fumigation, and 
are applicable for the disinfection of apartments, etc. I shall not under- 
take to enumerate the various articles of this class that have been used 
from time to time, but shall simply confine myself to a description of a 
few of the leading ones, such as experience demonstrates to be effective. 

A number of chemical substances are known to evolve oxygen very 



340 PEOPHYJ.AXIS OF DISEASE IN CHILDREN. 

freely when brought in contact with organic bases, and in this manner dis- 
integration of the obnoxious matters is presumed to take place. Chlorine, 
bromine, nitrous fumes, and ferric compounds are supposed to disinfect 
to some degree by this method. With respect to the chemical reactions 
that take place in the use of the other substances which will be mentioned 
farther on, very little appears to be known. 

Sulphur Dioxide. — The most available, inexpensive, and reliable disin- 
fectant that can be employed for fumigating apartments and preventing the 
spread of exanthematons diseases is sulphur dioxide, (SO2). The Greeks 
and Romans were acquainted with the preservative properties of this gas, 
and used it as an autifermeutative in wine. It is two and a quarter times 
as heavy as air, and is usually generated by burning sulphur. It has a 
peculiarly pungent and disagreeable odor, which is perceived when a sul- 
phur match is ignited. Guyton de Morveau, who first studied its action, was 
of the opinion that it would completely disinfect miasms. Its chemical 
action is supposed to be due to its power to deoxidize, the resultant acid 
coagulating albuminous matter. For the disinfection of rooms recently 
vacated by diseased persons, three pounds of sulphur should be burned for 
each thousand cubic feet of air space. The sulphur can best be ignited by 
pouring over it two or three ounces of alcohol and applying a lighted match. 
The room during the entire period of fumigation should be kept completely 
closed, and about twenty- four hours afterwards opened and thorough ven- 
tilation allowed. Before using this agent, however, all carpets should be 
taken up, the wall-paper removed and burned, the hangings thoroughly 
loosened, and every part exposed so that the gas can penetrate every- 
where. That sulphur dioxide has a direct action upon the vitality of the 
germs of disease follows from the statement made by Sternberg, who says, 
"In the proportion of one to two thousand, in an aqueous solution, SOg 
kills micrococci in two hours." Koch asserts that anthrax-bacilli are de- 
stroyed in a one-per-cent, solution in thirty minutes. The experiments of 
Baxter led him to the conclusion that " it is the most powerful volatile dis- 
infectant known." Sulphurous acid and sulphur dioxide are both destroyed 
by chlorine and permanganate of potassium, and should never be used in 
conjunction with either. The great solubility of sulphurous acid renders 
it one of the most valuable substances with which to disinfect liquids. 
Dr. Edson, of the New York Board of Health, in a recent report, says that 
sulphur dioxide is the most practicable and reliable means that he has ever 
seen employed for the disinfection of the exanthemata and diphtheria. 

Chlorine. — This is a pale yellowish-green gas at ordinary temperatures, 
about two and a half times as heavy as ordinary air. It is a powerful 
oxidizing agent, and extremely irritating to the air-passages when inhaled. 
It decomposes ammonia and sulphuretted hydrogen, and aifects all com- 
pounds arising from the putrefaction of organic matter. It is commonly 
used for the same purpose as sulphur dioxide, and, like that agent, renders 
the occupation of the apartments temporarily impossible. It bleaches 



PROPHYLAXIS OF DISEASE IN CHILDREN. 341 

organic matters aud destroj^s odors, either by withdrawing hydrogen or by 
direct oxidation. Chlorine is usually generated by means of chloride of 
lime, moistened either with water or with dilute sulphurous acid. There 
are several popular disinfectants which contain this gas in sufficient propor- 
tions to be of service : among these may be mentioned Piatt's chlorides, 
Labarraque's solution, and Javelle water. Chloride of lime is often used 
without the addition of an acid, being scattered as a powder in vaults, 
privies, and gutters. Bromine and iodine have properties similar to chlo- 
rine, though they are not so powerful in their action, and should not be 
relied upon when better substances can be procured. Iodine can be liberated 
from the scales by simply applying heat underneath a plate upon which 
they have been scattered. 

Fumigation should always be regarded in the light of an accessory, and 
should be, when practicable, accompanied by the processes of baking, steam- 
ing, and washing. All the wood-work — walls, floors, and furniture — must 
be rubbed down and washed with a solution of carbolic acid, one pint to 
the gallon of water, or a solution of bichloride of mercury, an ounce to the 
gallon of water, and the clothing and bedding baked, or washed in a solu- 
tion of chloride of lime. A failure to make these processes complete by 
leaving a single place or article overlooked will create a new centre for 
infection, and all the work will have been in vain. 

Carbolic Acid. — An important advance was made in disinfectants when 
the virtues of this substauce were discovered and brought forward. The 
great advantage of it, as a liquid, is that it is slightly volatile, and there- 
fore capable of being sprinkled in apartments and upon substances where 
it will penetrate every corner and crevice and be of service. It requires 
about twenty-five parts of water for thorough solution, and in this pro- 
portion is a powerful disinfecting liquid against all contagion. It coagu- 
lates albumen in the proportion given, and enters readily into union with 
organic substances wherever it meets them. Dr. Sansom has shown that 
a mixture of carbolic acid and glycerin is a delicate and effective appli- 
cation for disinfecting disease in the skin. Its chief property and that 
of the compounds associated with it is the power of destroying vegetable and 
animal organisms and preventing putrefaction and fermentation in them. 

Bichloride of mercury in solution is the most powerful and remarkable 
disinfectant known to science. Investigation shows that it is a deadly poison 
to all tlie lesser forms of life, which it kills instantly when employed 
in proper quantities. It cannot be used in connection with lead, tin, or 
copper, owing to its corroding qualities. Its power to destroy germs, even 
in dilute solution, is unique. In the proportion of one to five hundred 
it destroys vitality in ten seconds, in one to two thousand in one and one- 
third minutes, and in one to twenty thousand in from fifteen to twenty 
minutes. Thus it will be seen that time is an element always to be con- 
sidered when the solutions are used in ordinary proportions. 

The fact that corrosive chloride combines with albumen leads to the 



342 PROPHYLAXIS OF DISEASE IN CHILDREN. 

conclusion that it interferes somewhat with the process of destruction, and 
this is always to be remembered when using it as a disinfectant. 

The following solution is recommended by Sternberg as quite capable 
of killing all the germs of infectious diseases : bichloride of mercury, four 
ounces ; sulphate of copper, one pound ; water, one gallon. 

Dr. Parsons recommends the following solution as suitable for clothing, 
excreta, etc. : bichloride of mercury, half an ounce ; hydrochloric acid, one 
ounce ; aniline blue, five grains ; water, five gallons. Mix. This is the 
standard Solution No. 1 of the Public Health Association, and has been 
tested thoroughly. It should be labelled " poison." 

Sewage. — A large number of substances have been proposed for the 
disinfection of sewers, cesspools, and water-closets. The mercurial mineral 
salts are not applicable to sewers or drains, owing to the fact that they 
corrode the metallic pipes. Carbolic acid, crude, dissolved in water in the 
proportion of one to fifty, is a very efficient arrester of decomposition in 
drains and cesspools, and is in every way preferable. Calvert's powder, 
composed of about twenty-five parts of carbolic acid and seventy-five parts 
of alumina and silica, is applicable to the same conditions of use as quick- 
lime. 

The solid absorbent disinfectants, such as dry earth, charcoal, sulphate 
of iron, chloride of zinc, and chloride of lime, will be found to be efficient 
in drains and sinks under ordinary circumstances. It should be strictly 
enjoined, however, that under no circumstances are the dejecta of yellow 
fever, cholera, and typhoid fever patients to be emptied into sewers or privy- 
vaults until they have been thoroughly disinfected by the standard solution 
of mercuric chloride which has been recommended. Filth such as is found 
in closets, sinks, and privies, it should be remembered, is the chief source 
of nutrition for the different disease-germs, and therefore such places cannot 
be too clean nor avoided too widely. Let them be cleaned out often, after 
being disinfected ; and do not allow accumulations to take place under any 
circumstances, always remembering that bad odors are the best, if not a 
certain, indication that something is out of order and that there is danger 
ahead. 

Sternberg advocates a dilute chloride-of-lime powder composed of one 
pound of chloride of lime and nine pounds of plaster of Paris. This is 
clean to handle, and can be sprinkled over everything fearlessly. 

Perchloride of iron is useful for the disinfection of sewage, and when 
added to it throws down a precipitate of ferric oxide, which is due to its 
action upon the sulphide of ammonium nearly always present in sewage. 
It is conjectured that this reaction leads to the liberation of sulphur, Mdiich 
in turn acts as a disinfectant. 

Permanganate of potassium prevents putrefaction in sewage for a short 
time, and also acts as a deodorant ; but it is necessary to use it in large and 
expensive quantities to get these results, and hence it is not practical. 



SCHOOL-HYGIENE. 

By D. F. LINCOLN, M.D. 



The subject before us is readily divided into the two branches of per- 
sonal and external hygiene. Under the former we shall consider the facts 
of good or poor health in the individual, his habits and occupations as a 
scholar, and their influence upon his development. In doing this, the 
resources of medicine and educational science should be combined. The 
second part of the paper will include such architectural and engineering 
details as seem useful in establishing external conditions favorable to health 
and a normal development. 



I. PEESOE"AL HYGIENE. 

It is obvious that we must here exclude from consideration a great 
number of matters which apply equally to all children, whether inmates 
of schools or not, and that we must limit the discussion to such things as 
are specially under the influence of the school and its work. Under this 
limitation we find that the subject unavoidably presents itself in the form 
of a list of complaints : it might with equal propriety be termed a " School- 
Pathology." 

The aflfections which originate in school-influences may be roughly 
divided into those in which overwork is, in a general way, the chief cause, 
and those which are not so caused. Overwork and depressed vitality are 
largely responsible for the following complaints in school-children : dys- 
pepsia, headache, nervous derangements, chorea, epilepsy, neurasthenia, 
backache, menstrual disorders, and, in some cases, consumption. Spinal 
deformities, and diseases of the eyes, are conveniently treated apart from 
this list of aflections. The subject of physical education, and a discussion 
of school-programmes of daily work, conclude this part of the subject. 

AILMENTS FKOM DEPKESSED VITALITY. 

Physical debility, in one form or another, is plainly a chief cause of the 

ailments enumerated below, although in some cases it is necessary to allow 

343 



344 . SCHOOL-HYGIENE. 

largely for the presence of other causes, as in the case of eye-diseases and 
spinal deformity. 

The public schools of this country have often been accused of over- 
working the pupils. In the discussions of this subject it has naturally hap- 
pened that physicians have been prominent as accusers, while, just as 
naturally, many teachers have shown a tendency to excuse. Some of the 
most eminent educational authorities, however, have been most severe in 
their comments on the existing conditions of school-life. 

It is to be feared that the schools of Boston set the example of " high- 
pressure education" to the rest of the country. Such is the testimony of 
the late John D. Philbrick,'^ so long superintendent of the schools of that 
city, who gives a striking picture of the way in which it was introduced. 

According to Philbrick, the schools were in a lethargic state previous to 
1845, when the influence of Horace Mann aroused them. At that time the 
oldest classes of the grammar-schools (about the age of fifteen) were first 
subjected to competitive written examinations. This woke them up to an 
intense activity ; " the highest kind of high pressure was inaugurated in a 
day." The competitive examination was discontinued after a few years, 
but the fear of it survived, and efforts were constantly made to revive it. 

Examinations at all stages, and very frequently repeated, are a charac- 
teristic of recent plans of education. They are extremely useful, in fact. 
But they are worse than futile when instituted merely to make a visible 
showing for work already well done, or when a child who has been faithful 
for a year is kept in needless but anxious suspense about his promotion. 
Examinations have also a habit of coming at the close of the spring term, 
when everybody feels tired ; some schools wisely suspend other work, to 
give as much